Flu Shot Medicare Fee Schedule

Payment Allowances And Effective Dates For The 2020

Payment limits and effective dates for newly approved and marketed influenza vaccines will be posted to this webpage.

During the flu season, if the FDA approves new vaccines, well update our pricing table.

Get More Information On Frequency & Coverage Coding And Billing

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Does Medicare Advantage Cover Flu Shots

Medicare Advantage plans, which are often referred to as Medicare Part C, are offered by private insurance companies and typically include Part D, or prescription drug coverage. These plans provide a way to get additional Medicare benefits based on your individual needs.

Medicare Advantage plans cover 100% of the Medicare-approved amount for an annual flu shot, says Christian Worstell, a North Carolina-based licensed insurance agent. Plus, he notes, Medicare beneficiaries with a Medicare Advantage plan typically wont have to pay a coinsurance or copayment for the flu shot. Thats true as long as you visit a doctor who accepts Medicare and the terms of your Medicare Advantage plan, he says.

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Billing Considerations For Part B Vaccines

Whether participating or non-participating in Medicare, physicians must accept assignment of the Medicare vaccine payment rate and may not collect payment from the beneficiary for the vaccine.

Non-participating physicians may choose not to accept assignment on the administration fee. When a non-participating physician or supplier provides the services, the beneficiary is responsible for paying the difference between what the physician or supplier charges and the amount Medicare allows for the administration fee. The limiting charge provision does not apply to the influenza benefit.The influenza and pneumococcal vaccines and the administration of these vaccines are not subject to the Medicare Part B deductible or co-insurance. Medicare pays at 100% of the allowable amounts. However, the Hepatitis B vaccine and administration are subject to the deductible and co-insurance. Medicare pays at 80% after the patient has met their Part B deductible.Medicare will pay two administration fees if a beneficiary receives both the influenza virus and the pneumococcal vaccine on the same day.Claims for the hepatitis B vaccine must include the name and NPI of the ordering physician, as Medicare requires that the hepatitis B vaccine be administered under a physicians order with supervision. This is not necessary for the influenza and pneumococcal vaccines for which Medicare does not require a physician’s order or supervision.

Medicare Announces Influenza Vaccine Payment Rates For 2021

The Centers for Medicare & Medicaid Services has announced the Medicare Part B payment allowances for various influenza vaccines for the 2021-2022 flu season. Effective dates, available on the CMS pricing webpage, vary somewhat by vaccine, but are generally from August 2021 through July 2022. The payment allowances range from about $10 to $66, depending on brand and formulation .

The Medicare Part B payment allowances for flu shots represent 95% of the average wholesale price, except for vaccines given in a:

• Hospital outpatient department,

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Does A Person With Medicare Get Flu Shots For Free

If a person has Medicare Part B, a Medicare Advantage plan, or private health insurance, they can get a flu shot for free.

The Affordable Care Act requires that insurance companies cover the cost of the flu shot. Plus, under the ACA, insurers cannot charge a copayment, per the Department of Health & Human Services.

A person should check with the site providing the shot to make sure they accept assignment from Medicare or accept Medicare Advantage. People with private insurance should check their plan to make sure they can get the shot from a particular location for free.

Some insurance plans cover the shot only if a person receives it from their doctor. Other plans provide coverage if the shot comes from certain other locations as well.

Seasonal Influenza Vaccines Pricing

The Medicare Part B payment allowance limits for seasonal influenza vaccines are 95% of the Average Wholesale Price , as reflected in the published compendia.

In hospital outpatient departments, payment is based on reasonable cost.

Annual Part B deductible and coinsurance amounts dont apply for the influenza virus vaccinations. All physicians, non-physician practitioners, and suppliers who administer these vaccinations must take assignment on the claim for the vaccine.

Annual Influenza Vaccine season starts on August 1 and ends on July 31 of the following year.

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Medicare Part D: Vaccine Coverage

Payment for Part D-covered vaccines and their administration are made solely by the participating prescription drug plan. This includes all preventive vaccines not covered under Medicare Part B.

When providing a Part D covered vaccine to a Medicare patient, the physician should charge the patient for the vaccine and its administration. To facilitate the patient’s reimbursement by his or her Part D plan, the physician’s office should complete a CMS-1500 claim form for the vaccine and administration service and give it to the patient to file as an unassigned, out-of-network claim.Some patients may also request a prescription for preventive vaccines and their administration to meet their Part D plan requirements to have this prescription filled by contracted providers .

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Find A Flu Shot Location Near You

If you have a UnitedHealthcare health plan, you can get a flu shot at more than 50,000 locations.

To find a flu shot location using the map, enter your ZIP code and select a pharmacy in your area, then select Find my flu shot to see results within a 20-mile radius from the center of your ZIP code.

Note: If you’re using a screen reader, use the list of Participating pharmacies, then select a pharmacy to find a location near you.

• Those with specific health conditions

Billing Flu Shots To Medicare And Commercial Insurance Companies

Since it is now flu season I have been getting a lot of questions on how to bill flu shots to commercial insurance companies and Medicare. The codes used for a particular vaccine will vary depending on intramuscular vs. intranasal use, age of the patient, formulation, preservative-free, and split or live virus. If you are unsure of what code to use I suggest looking at the package informationthat came with the vaccine. Usually, you can find the code on the packaging, and if you cant find it in the documentation then call the supplier.

This is how most of our primary care practices bill for flu shots. Your situation may be different so make sure to check all the influenza vaccine codes 90654-90668 and use the appropriate code for the vaccine administered to the patient.

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Who Should Not Get A Flu Shot

Talk with a doctor before getting a flu vaccine if you:

• Have a severe allergy to eggs
• Have had a severe reaction to an influenza vaccination
• Children younger than 6 months of age
• People who have a moderate-to-severe illness with a fever
• People with a history of GuillainBarré Syndrome that occurred after receiving the influenza vaccine and who are not at risk for severe illness from influenza should generally not receive the vaccine. Tell your doctor if you ever had Guillain-Barré Syndrome. Your doctor will help you decide whether the vaccine is recommended for you.

You can get a flu vaccine at the same time you have a respiratory illness without fever or if you have another mild illness.

When Should You Get Your Flu Shot

Its generally recommended that people get a flu vaccine by the end of October, according to the CDC. This is especially important because of the ongoing spread of COVID-19. The flu season peaks often in February and can last until May, so you can still get the flu vaccine later. No matter when you get your flu shot, it will still be valuable to help protect you for the rest of the flu season. Talk to your provider about the best time to get your flu shot. Remember to ask about other vaccines you might need to protect yourself this year too.

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Which Medicare Services Cover Flu Shots

Flu shots are covered under Original Medicare and Medicare Advantage, so long as your provider or pharmacy is one that accepts Medicare payment.

Because Medicare Advantage plans must offer at least the same coverage as Original Medicare, your Medicare Advantage plan also covers flu shots once a flu season. Private health plans may not require that you get a referral to receive the flu shot, but they may require that you receive the shot within your planâs network of providers. Like Original Medicare coverage, Medicare Advantage plans cover the full cost of the flu shot. Overall out-of-pocket costs such as premiums and deductibles may vary for these plans, but the deductible does not apply in this situation, if the plan has one.

How To Avoid Getting And Spreading The Flu:

• Get the flu shot every year
• Avoid large crowds and stay home when youre sick
• Wash your hands well and often with soap and warm water for at least 15 seconds. If soap and water are unavailable, use a hand sanitizer with at least 70% alcohol
• Cover your mouth and nose with a tissue when you cough or sneeze and throw the tissue out immediately. Wash hands afterwards. Cough in your upper sleeve if you dont have a tissue
• Don’t touch your face
• Clean surfaces and shared items

Important! You may not know that you have become infected with the flu virus. Adults infected with the flu can infect other people one day before they even have symptoms and up to five days after becoming sick. Children and people with weakened immune systems may be able to spread the virus for even longer.

Follow the above tips to stay healthy throughout the year.

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What Should You Know About Seasonal Flu This Year

Watch as Dr. Mayrene Hernandez, Medical Director for UnitedHealthcare, answers some common questions about the upcoming flu season.

Video transcript

Its important to get the flu shot every year. The flu shot protects you against the flu virus.

It can help you prevent a hospitalization or complications of actually getting the flu.

It is very easy to find a local pharmacy or your providers office. Its offered in multiple, multiple locations.

Not only that, its also covered at 100% in most plans.

Video transcript

Who should get the flu shot? Everyone above the age of six months or older. Adults over the age of 65, pregnant women, or those with chronic conditions like diabetes, asthma, coronary artery disease, or renal disease. But you should also get it even if youre healthy.

The Benefits Of Getting A Flu Shot

Influenza is a common and potentially serious viral infection that can lead to hospitalization and sometimes even death. Receiving the annual flu vaccine is one of the best ways to protect against infection and subsequent complications, reports the CDC.

The flu shot can:

• Reduce the risk of flu illness by 40% to 60% among the general population during seasons when current flu viruses are well-matched to those used to make flu vaccines
• Reduce the severity of illness in people who get vaccinated but still get sick
• Prevent millions of illnesses and flu-related doctor visits annually
• Reduce the risk of flu-associated hospitalization
• Help protect people around the person who gets vaccinated

The CDC currently recommends that adults at least 65 years old receive either a higher dose or adjuvanted flu vaccine over the standard dose vaccine for additional protection, due to the fact that older adults are at higher risk of having serious health complications from the flu. The three recommended vaccines include the Fluzone High-DoseQuadrivalent vaccine, Flublok Quadrivalent recombinantflu vaccine and Fluad Quadrivalent adjuvanted flu vaccine. All of these vaccines are quadrivalent vaccines, meaning they protect against four flu viruses.

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Payment Allowances And Effective Dates For The 2022

Payment limits and effective dates for newly approved and marketed influenza vaccines will be posted to this webpage.

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What Are The Risks Of Getting A Flu Vaccine

The viruses in the flu shot are killed , so you cannot get the flu from a flu shot. The risk of a flu shot causing serious harm, or death, is extremely small. However, a vaccine, like any medicine, may rarely cause serious problems, such as severe allergic reactions. Almost all people who get the influenza vaccine have no serious problems from it.

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