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!