Boost Your Bottom Line with In-Home Preventative Vaccine Administration

As some may recall, the Centers for Medicare & Medicaid Services (CMS) rolled out a program back in 2021 where pharmacies were eligible to receive additional reimbursement for administering COVID-19 vaccinations to certain Medicare homebound patients (see October 2021 PAAS Newsline article, COVID-19 Vaccine Administration Audit Risk). As of January 2024, pharmacies can take advantage of a similar program where Medicare beneficiaries who meet the necessary criteria can be vaccinated for the other preventative vaccines covered under Medicare Part B – influenza, hepatitis B, and pneumococcal.

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As explained on CMS’s In-Home Vaccine Administration: Additional Payment website, Medicare beneficiaries who have “difficulty leaving the home or faces barriers to getting a vaccine in settings other than their home” would be considered eligible. Examples given by CMS include:

  • They have a condition, due to an illness or injury, that restricts their ability to leave home without a supportive device or help from a paid or unpaid caregiver
  • They have a condition that makes them more susceptible to contracting a disease
  • They’re generally unable to leave the home. If they do leave the home, it requires a considerable and taxing effort
  • The patient is hard-to-reach because they have a disability or face clinical, socioeconomic, or geographical barriers to getting a vaccine in settings other than their home. These patients face challenges that significantly reduce their ability to get vaccinated outside the home, such as challenges with transportation, communication, or caregiving.

As evident from this guidance, CMS leaves the standard to meet this requirement relatively open to interpretation. In addition, pharmacies do not need to certify that the Medicare beneficiary is homebound, which is a departure from the requirements under the Medicare home health benefit. However, PAAS National® recommends documenting the rationale for the patient qualification [for the vaccine administration at home] on the prescription.

As part of the program, pharmacies can earn an in-home vaccination payment of $38 in addition to the $30 standard administration amount, totaling $68 (subject to rate adjustments based on geographical location) per patient if the sole purpose of the visit is to administer vaccine(s). Visit the CMS website for more information on additional payment scenarios.

PAAS Tips:

  • Ensure appropriate CPT code use for vaccine administration: flu (G0008), hepatitis B (G0010), pneumococcal (G0009)
  • Utilize HCPCS Level II code M0201 to bill for the additional payment amount earned by administering the vaccination as part of the in-home program

Meredith Thiede, PharmD
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