Posted and filed under Coding, Compliance.

Please refer to our accompanying article Vaccine Administration Counseling for more information on vaccine coding and documentation.

The Vaccines for Children (VFC) Program is a federally funded program that offers vaccines at no cost for eligible children through doctors enrolled in the program. The CDC provides information for Healthcare providers to become a VFC provider.

While CDC has the lead responsibility for policy development and implementation of the VFC program, the VFC program is contained in the Medicaid law and is funded by the Federal Government through the Centers for Medicare and Medicaid Services (CMS), Medicaid program. Each State Medicaid program must file a Medicaid State plan amendment covering its Pediatric Immunization Program in order to receive Federal funds to operate its Medicaid program and to receive vaccines from the VFC program.

The VFC program provides routine vaccines to all states, the District of Columbia, and territories for participating healthcare providers. All vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) and approved by CDC and HHS are covered under the VFC Program at no cost to the participating healthcare provider. You don’t have to be a Medicaid provider to participate in VFC. Any healthcare provider authorized to prescribe vaccines under your state law can be a VFC provider.

State Medicaid agencies have the option to require participation in the VFC Program. Some state agencies do not specifically require Medicaid providers to register as VFC providers, but they may refuse to cover the cost of vaccines that are obtained through private sources. It is to the benefit of the Medicaid agency to require provider participation in the VFC program because of reduced vaccine costs.

Within broad national guidelines established by the Federal government, each State Medicaid Program:

  • Establishes its own eligibility standards,
  • Determines the type, amount, duration, and scope of services,
  • Sets the rate of payment for services; and
  • Administers its own program.

Thus, the Medicaid program varies considerably from State to State. However, one thing that remains constant from State to State regardless of their programmatic policy differences, is that all State Medicaid programs recognize and encourage their participating physicians to enroll in the VFC Program. For more information on individual state VFC coverage, review the VFC State Awardees website.

Each provider will need to review the reimbursement policy of the particular Medicaid administrator for their patient to determine how to bill for this service. Although providers shall only be reimbursed for the administration of the vaccine, some plans require that serum code(s) must be included on the claim to meet regulatory and Healthcare Effectiveness Data and Information Set (HEDIS®) reporting requirements that members are receiving the proper immunizations. Other plans may require billing the serum code(s) with a specific modifier along with the administrative codes.