(Feb. 21, 2025) –Medicare's MLN Matters MM13923, released on Jan. 16, 2025, includes important information for rural health clinics regarding Medicare Part B coverage of preventive vaccines. Medicare Part B pays for pneumococcal, influenza and COVID-19 vaccines and their administration in RHCs and federally qualified health clinics at 100 percent of reasonable costs under section 1833(a)(1)(B) of the Social Security Act. For RHCs, Medicare does not include the costs associated with these vaccines and their administration when the All-Inclusive Rate is determined, and Medicare does not subject them to the payment limit.
Starting Jan. 1, 2025, Medicare Part B pays for hepatitis B vaccines like they do pneumococcal, influenza and COVID-19 vaccines in RHCs and FQHCs. Starting July 1, 2025, RHCs and FQHCs can bill for all four types of Part B preventive vaccines: pneumococcal, influenza, hepatitis B and COVID-19 and their administration at the time of service with or without a qualifying visit. RHCs and FQHCs can bill HCPCS code M0201 for an in-home additional payment for Part B preventive vaccine administration only if a home visit meets all the requirements of both 42 CFR 405 Subpart X, for RHCs and FQHCs services provided in the home, and 42 CFR 410.152(h)(3)(iii), for the in-home additional payment for Part B preventive vaccine administration.
Medicare requires RHCs and FQHCs to reconcile annually payments received at the time of service with the facilities' actual vaccine and vaccine administration costs on their cost reports, including any additional in-home costs. Medicare Part B pays the claims like other Part B vaccine and vaccine administration claims:
- Vaccine products at 95 percent of the Average Wholesale Price
- Vaccine administration according to the National Fee Schedule for Medicare Part B vaccine administration
The Part B vaccine administration fee schedule includes locality-adjusted payment rate files for codes G0008, G0009, G0010, 90480 and M0201, with the annual update applied for the calendar year 2025. You can find these files on the CMS Vaccine Pricing page under the "Seasonal Flu Vaccine" tab for the influenza, pneumococcal and hepatitis B payment rates and the "COVID-19 Vaccines & Monoclonal Antibodies" tab for the COVID-19 vaccine payment rates.
For more information, review MLN Matters MM13923.
--Karen Braman