Medicare will cover both the seasonal influenza vaccine and a vaccine against the pandemic influenza A(H1N1) virus, once one becomes available this fall.
In a notice to physicians and other health care providers, officials at the Centers for Medicare and Medicaid Services said that the same billing rules will apply to the pandemic H1N1 vaccine and the seasonal vaccine. However, because the pandemic H1N1 vaccine will be provided at no cost by the government, Medicare will pay providers only for its administration.
The CMS has issued two new billing codes to address H1N1 vaccine this season. Providers can use G9141 for pandemic influenza A(H1N1) immunization administration, including physician counseling of the patient and family. Payment for G9141 will be the same as that for the administration of the seasonal influenza vaccine. The CMS also has created a billing code, G9142, for the pandemic influenza A(H1N1) vaccine itself. However, that code will not trigger payment. Neither will Medicare pay for an office visit when its sole purpose is administration of either seasonal influenza vaccine or pandemic H1N1 vaccine.
The CMS has notified its carriers to prepare for early claims for the seasonal influenza vaccine. “We understand that such preparations are critical for the upcoming flu season, especially in planning for the influenza [A(H1N1)] vaccine,” the CMS wrote online.
Private insurers are also planning to extend coverage to the pandemic H1N1 vaccine. Susan Pisano, a spokeswoman for America's Health Insurance Plans, the leading insurance industry trade group, said that if an insurer typically covers seasonal influenza vaccine, it will probably cover the pandemic H1N1 vaccination in the same way. As the CMS has announced for Medicare, private plans will not reimburse providers for the cost of the pandemic H1N1 vaccine.