Pamela Paparone, DNP(c), APN
Infectious Disease Specialists
AtlantiCare Regional Medical Center
New Jersey Immunization Network
April 23, 2014
Adult Immunization and Reimbursement
in New Jersey
Adult Vaccination Rates Healthy People 2020 (2008 data)
Influenza
Pneumococcal vaccine
Hepatitis B
ACIP Recommended Vaccines for
Children
Diphtheria
Hib
Hepatitis A
Hepatitis B
HPV
Influenza
Measles
Meningococcal
Mumps
Pertussis
Pneumococcal
Polio
Rotavirus
Rubella
Tetanus
Varicella
Vaccines for Children (VFC) Medicaid and Managed Medicaid
• All states
• Ineligible on the 19th birthday
• VFC part of Medicaid law
• VFC - Medicaid-eligible, uninsured, American Indian or
Alaska Native, or underinsured children at a FQHC or RHC
Federally Qualified Health Center FQHC
Federally qualified health center (FQHC) are health care
organizations that receive financial grants under Section 330
of the Public Health Service Act
Enhanced reimbursement from Medicare and Medicaid and
other benefits
Underserved area or population
Sliding fee scale
Comprehensive services
Ongoing quality assurance program
Governing board of directors
Section 317 Vaccines
Adults not covered by insurance
Immunization grant program – discretionary - public clinics
Discretionary funding for those not covered by VFC)
Immunization infrastructure for direct provision of vaccine,
training and monitoring of providers, immunization
registries, school based and community based programs,
education, surveillance, and population needs assessments
Section 317 Vaccines
Separate pots for VFC and Section 317 Vaccines
In NJ, Section 317 vaccines are used for adults and for
vaccination in the rare outbreak scenario
Hib, hepatitis A, hepatitis B, influenza, MMR, Tdap,
pneumococcal, meningococcal, polio, varicella, Zostavax,
and HPV
Section 317 Vaccines In circumstances other than "exceptions" specified in the
policy, 317 vaccines may not be used to vaccinate:
Fully insured
Traditional Medicaid
• Title XIX of the Social Security Act is the Federal/State
entitlement program for low income adults and children
• Established in 1965
• Each state determines eligibility, scope of services, rate of
payment for services and administration
• Fee for service
Managed Medicaid Started in NJ in 1995
HMO managed care
New Jersey - Managed Medicaid (HMO)
United Health Care Community Plan – New Jersey (All counties)
Horizon – New Jersey Health (All counties)
Amerigroup – New Jersey (All counties except Salem)
Healthfirst – New Jersey (Ten counties)
Managed Medicaid Four Managed Medicaid HMO Plan categories:
“A” No monthly premium, No copayment
“B” No monthly premium, No copayment
“C” No premium for children*, Copayment of $5.00 - $10.00
“D” Premium of $40.50 – to $134.00 per month per family and
a copayment of $5.00 - $35.00
What Adult Vaccines are Covered by
New Jersey Medicaid?
Traditional Medicaid and
Managed Medicaid
Barriers Facilitators
No pharmacy vaccination access
Immunizations limited to certain
providers
Medicaid coverage of specified
vaccines not on website and
difficult to determine
Insufficient transparency
Not all providers stock
recommended vaccines
Primary care provider provide
some vaccines
NJIIS system widely used
Private Insurance and
Adult Vaccination Coverage
Private Insurances
Over 300 insurance carriers nationwide, thousands of
policies, patient must know their own policy coverage for
immunization
Billable
Affordable Care Act may change vaccine coverage
No co-pay for preventative services
Private Insurance
Barriers Facilitators
Individual lack of
knowledge about vaccine
coverage
Cost of vaccines may or
may not covered by
insurance
NJIIS system not widely
used
Most providers willing to
vaccinate these patients
providing patients
understand the cost if not
covered by insurance
No co-pay for preventative
services
Pharmacy access
Medicare Influenza
Covered benefit under Part B
High Dose influenza vaccine is covered for those 65 and over
If you accept assignment, you may not apply a co-pay or deductible to the vaccine or administration of the vaccine
Medicare will cover more than one dose in a year
Medicare will cover influenza vaccine if given at the same time as
pneumococcal vaccine*
Medicare
Pneumococcal
Covered benefit under part B
Polysaccharide and conjugate versions are covered
Covered if patient is uncertain of vaccination history and
receives the pneumococcal vaccine
Medicare
Hepatitis B
Covered benefit under part B for those individuals considered
to be high-risk
Medicare
Hepatitis B
May be a covered benefit under part D for low risk individuals
If individual has Part B and Part D, they are considered insured
and may not use Section 317 vaccines
If individual does not have Part D, they are considered
underinsured and may use Section 317vaccines
Medicare Tetanus toxoid
Covered benefit under part B *
Tdap not covered benefit under part B, may be covered under part D
If individual has Part B and Part D, they are considered insured and may not use Section 317 vaccines
If individual does not have Part D, they are considered underinsured and may use Section 317vaccines
Medicare
Herpes Zoster Vaccine (Zostavax)
May be a covered benefit under part D (secondary coverage)
If individual has Part B and Part D, they are considered insured
and may not use Section317 vaccines
If individual does not have Part D, they are considered
underinsured and may use Section 317vaccines
Medicare
Barriers Facilitators
Uncertainty about
coverage for Zostavax
Lack of knowledge about
existence of Section 317
funding
NJIIS system not widely
used
Part B coverage for
influenza, pneumococcal,
and hepatitis B
Pharmacy access
Adult Immunization Trends
Vaccines.gov – vaccine finder – enter zip code
Rite-Aid, CVS, and Walgreens Pharmacies + Atlantic County
Health Department
Pharmacies are a new trend in vaccine access
Adult Influenza Vaccination 2011-2012
Physician Office Pharmacy Workplace
~18 38%
18-49 30%
50-64 38.2%
>65 48%
20% 17%
28% 15%
19% 20%
28%
References
CDC. (2013). Questions answered on vaccines purchased
with 317 funds. Retrieved from
http://www.cdc.gov/vaccines/imz-managers/guides-
pubs/qa-317-funds.html
Healthy People 2020
New Jersey Department of Health website
Vaccines.gov
Questions?
Thank you!