Seasonal flu vaccine is available for all Texas Medicaid clients.
For clients who are 6 months through 18 years of age, the vaccine is available through Texas Vaccines for Children (TVFC) at no cost to the client or provider. To obtain the vaccine free of charge, providers must enroll in TVFC. The enrollment application can be found on the Department of State Health Services (DSHS) website. Enrolling providers must meet TVFC requirements listed in the application. This includes pharmacies administering vaccinations as of October 1, 2009.
Providers must not charge Medicaid clients for any out-of-pocket costs, including administration or vaccine fees.
If the vaccine is obtained from TVFC for clients who are 19 years of age or younger, providers must bill Medicaid for the administration fee and the vaccine, but will be reimbursed only for the administration fee. Providers who do not use TVFC vaccine for Medicaid clients younger than 18 years of age will not be reimbursed for the cost of the vaccine.
A provider that chooses not to enroll with TVFC may refer clients to a local TVFC provider or to the local county health department; however, providers are encouraged to provide seasonal influenza vaccines for Medicaid clients rather than divert them away from the medical home to local health departments or pharmacies. A TVFC-enrolled provider can be located by calling 1-800-252-9152.
For clients who are 19 years of age or older, both the vaccine and administration fees will be considered for reimbursement. The reimbursement amount depends on the type of seasonal influenza vaccine administered. The fee schedule with reimbursement rates is available on this website.
Providers are expected to follow current Advisory Committee on Immunization Policies (ACIP) recommendations for children and adults. ACIP states that all children who are 6 months through18 years of age should be vaccinated annually with seasonal influenza vaccine, with a focus on children who are considered to be at high-risk.
Medicaid pays for annual seasonal influenza vaccines for any client who wants to reduce the risk of becoming ill with influenza or of transmitting it. Special emphasis should be placed on vaccinating high-risk clients, as detailed within the ACIP recommendations. These include clients who have the following chronic disorders:
· Pulmonary, including asthma
· Cardiovascular, excluding hypertension
· Renal
· Hepatic
· Cognitive
· Neurologic or neuromuscular
· Hematological or metabolic, including diabetes mellitus
Unless clinically contraindicated, all clients within the Medicaid Enhanced Care Program or other Medicaid Managed Care Organization Disease Management programs would meet this high-risk definition.
Medicaid Managed Care Clients
For clients enrolled in one of the Medicaid managed care programs, STAR, STAR+PLUS, or STAR Health, providers should contact the client’s HMO for questions and billing information.
Providers can refer to the 2009 Texas Medicaid Provider Procedures Manual, Appendix H, “Immunizations,” on page H-1 for additional information.