Table 3.
Medicaid visit reimbursement rates for adult vaccinations (n = 15).
| Program | 99211 | 99281 | 99385 | 99386 | 99395 | 99396 |
|---|---|---|---|---|---|---|
| Connecticut | 18.14 | 11.73 | 96.35 | 112.99 | 78.54 | 86.68 |
| Delaware | 19.81 | 20.34 | 109.62 | 127.41 | 95.81 | 104.42 |
| Georgia | 17.46 | 17.28 | 75.38 | 75.38 | 75.38 | 75.38 |
| Illinois | 12.30 | 14.35 | 71.76 (PCP) | 104.96 | 64.40 (PCP) | 85.65 |
| Indiana | 9.98 | 15.25 | 69.80 | 81.60 | 61.69 | 67.52 |
| Iowa | 17.93 | 18.27 | 101.03 | 121.68 | 86.94 | 96.90 |
| Maryland | 17.40 | 19.85 | 96.88 | 113.97 | 79.03 | 87.23 |
| Mississippi | 16.09 | 17.67 | 93.37 | 93.37 | 76.81 | 76.81 |
| New York | 39.64 | 6.50 | 39.64 | 39.64 | 39.64 | 39.64 |
| North Carolina | 16.82 | 17.03 | 96.83 | 113.48 | 84.13 | 92.08 |
| Ohio | 13.43 | 11.62 | 68.22 | 56.62 | ||
| Pennsylvania | 20.00 | 16.19 | 20.00 | 20.00 | 20.00 | 20.00 |
| Utah | 16.12 | 16.12 | 16.12 | 16.12 | 16.12 | 16.12 |
| Virginia (+) | 13.77 | 14.79 | 89.52 | 79.78 | ||
| Wisconsin | 12.19 | 20.21 | 57.53 | 58.00 | 57.53 | 20.21 |
Source: MILKEN INSTITUTE/GWU/SPH Medicaid Provider Reimbursement for Adult Immunizations 2014.
Data Source: Document review and survey.
Florida does not provide coverage or reimbursement for any vaccines for non-institutionalized adult Medicaid beneficiaries.
Virginia (+): Visit = medical events when Evaluation/Management (EM) or preventive care services are rendered during an outpatient hospital clinic, office, or RQHC/RHC encounter (CMS Codes).
Illinois: 99385: rates were calculated by taking the allowed percentage of state maximum for the CPT code plus the adult rate ($38.56 for 99385-6, $43.15 for 99395-6).
Mississippi: HPV (90649) & FluMist (90660) administration not covered. Allows reimbursement of administration for influenza & pneumococcal vaccines with 99211 (90471= $18.52, 90472= $9.55)
Utah: Total REIMBURSEMENT = Vaccine CPT Code + ADMINISTRATION CPT CODE OR VISIT CODE.
RELEVANT CPT CODES
99211: Established Patient Office or other outpatient visit for evaluation and management that may not require the presence of a physician. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.
99281: Emergency department visit.
99385: New Patient, Initial Comprehensive Preventive Medicine Evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunizations(s), laboratory/diagnostic procedures; 18–39 years.
99386: New Patient, Initial Comprehensive Preventive Medicine (same as above); 40–64 years.
99395: Established Patient, Periodic Comprehensive Preventive Medicine Reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of appropriate immunization(s), laboratory/diagnostic procedures; 18–39 years.
99396: Established Patient, Periodic Comprehensive Preventive Medicine (same as above); 40–64 years.