Provider Notice issued 09/19/2016

Vaccines For Children (VFC) Program Changes Effective October 1, 2016

​To:

Federally Qualified Health Centers (FQHCs), Encounter Rate Clinics (ERCs), and Rural Health Clinics (RHCs)

​Date: ​September 19, 2016
​Re:

Vaccines For Children (VFC) Program Changes Effective October 1, 2016


This notice is to provide information regarding changes to the Vaccines for Children (VFC) program effective with dates of service on or after October 1, 2016. Changes to the program were previously announced via written notification dated August 24, 2016 (pdf) from the Illinois Department of Public Health (DPH) and the Illinois Department of Healthcare and Family Services (HFS).

Previously, All Kids participants ages 0 through 18 eligible under Illinois’ State-funded only program or Title XXI [21] of the Social Security Act, were eligible to receive free VFC vaccines through an Intergovernmental Agreement between HFS and IDPH. Effective October 1, 2016, children who have the state’s Title XXI [21] and State-Funded All Kids eligibility are no longer eligible to receive vaccines through the federal VFC program. Participants through age 18 with Title XIX [19] coverage continue to be eligible for vaccination through the VFC program.

To ensure correct reimbursement, providers must verify a child’s eligibility status through use of an eligibility system that will provide the Title XXI [21] and State-Funded information. The HFS MEDI system returns this information with verification of eligibility. The 270/271, Health Care Eligibility Benefit Inquiry and Response, transaction also provides eligibility/Title information in Loop 2110C, MSG01. The Chapter 300, Companion Guide provides HFS specific eligibility information. Providers using an outside billing vendor should contact their vendor in order to determine where and how the Title and State Funded information will be presented.

Clinics must privately purchase vaccines for administration to the Title XXI [21] and State-Funded All Kids eligible children and seek reimbursement from HFS or the HFS Managed Care Organization (MCO) reflected in MEDI. HFS will reimburse the cost of the vaccine fee-for-service (FFS). Providers must bill the MCO directly for children enrolled in managed care. The FFS reimbursement rates are published in the State Max column of the Practitioner Fee Schedule. Providers billing MCOs should reference the individual plan’s policies and procedures. Detailed billing examples can also be found on the HFS website (pdf).

Instructions and policies for clinics on how to bill vaccines FFS for Title XXI [21] and State-Funded All Kids eligible children specific to the VFC program changes are located on the Non-Institutional Providers webpage.

Federally Qualified Health Centers (FQHC), Rural Health Centers (RHC), and Encounter Rate Clinics (ERC) will receive their established encounter rate when vaccinating Title XXI [21] and State Funded children when there is a billable encounter. A billable encounter is a face-to-face office visit with a physician, Advanced Practice Nurse, or Physician Assistant.

In order to receive vaccine product reimbursement: 

  • A practitioner must order the vaccine and document the vaccination administration in the medical record as well as the practitioner’s medical record.

  • The clinic must use its fee-for-service NPI to bill the appropriate vaccine-specific procedure code with the ‘GB’ modifier on the Form HFS 2360 (pdf) paper claim form or electronically via the 837P claim transaction. 

  • The clinic must identify the NDC for the specific vaccine following the guidelines posted in Chapter A-200, Handbook for Practitioners Rendering Medical Services, Appendix A-6.

When reporting costs on the clinic’s annual cost report, costs associated with non-VFC vaccines billed fee-for-service should be reported separately, including allocation of administrative costs associated with these services. Refer to the cost report instructions for FQHCs and RHCs for the proper reporting of these costs.

For information about recommended vaccines for children, go to the Centers for Disease Control Website or the Illinois Chapter, American Academy of Pediatrics Website.

Questions regarding this notice should be directed to a Medical Assistance Consultant in the Bureau of Professional and Ancillary Services at 1-877-782-5565.

 

Felicia F. Norwood

Director

Illinois Bicentennial