2.1 Dosage-Based
Child Vaccine Assessment Methodology For Child Vaccines
2.1.1 For information
on Dosage Based SVPs as authorized providers, see TPM,
Chapter 11, Section 9.2. Under the dosage-based
assessment methodology, each state vaccine entity (e.g., a designated
state department, vaccine association or vaccine board) releases
a vaccine price list for each vaccine that is covered through its
program. This price list, known as the dosage-based assessment fee, is
based on bulk-vaccine rates the state is able to receive from either
the Centers for Disease Control and Prevention (CDC), or negotiations
with distributors. The vaccine price list is updated by the state and
lists the Current Procedural Terminology (CPT) code for the vaccine,
name of the vaccine, and corresponding price for each vaccine.
The
Defense Health Agency (DHA) will use a website for correspondence
of the dosage based assessment fee (price list) with the contractors.
The website is found here: https://health.mil/SVP.
The posted list may include a 1.8% adjustment factor for estimated vaccine
administration claims submitted without vaccines.
2.1.2 Providers,
clinics and hospitals send vaccine orders to the state, and the
state then purchases the vaccines at the bulk discounted rate and
delivers them to the providers.
2.1.3 Providers administering state-supplied
vaccines submit two claims to insurers: one using the provider’s
tax identification number for administration of the vaccine, and
one with the state vaccine entity’s provider number for the vaccine
itself with the dosage-based assessment charge from the state supplied
vaccine price list and vaccine CPT code. The SVP shall only be reimbursed
for supplied vaccines that are used to immunize TRICARE beneficiaries,
and only for those vaccines covered under TRICARE. Any other SVP
charges (e.g., professional or administrative fees) shall be denied.
The vaccine administration fee is charged separately from the vaccine
amount by the provider, and not the SVP, and this amount may be
reimbursed by TRICARE when the appropriate claim form is submitted.
2.1.4 A request
for reimbursement of dosage-based vaccines must be on an appropriate
claim form as prescribed in
32 CFR 199.7.
Submitted claims must be for a specific vaccine used to immunize
a specific TRICARE beneficiary. In addition, all other TRICARE claims
filing requirements must be met, with the exception of TRICARE’s
requirement for a National Drug Code (NDC) to be on the claim. In
other words, the SVP is exempt from the TRICARE reporting requirement
to include the NDC for vaccines that do not appear on the Medicare
pricing file [i.e., the additional coding requirement for pricing
of vaccines at the Average Wholesale Price (AWP)]. This SVP is exempt
from the NDC coding requirement because the SVP uses dosage-based
price list by CPT code, versus NDCs. The claim must include the National
Provider Identifier (NPI) for the SVP and the SVP dosage-based price
must be included as the billed charge on that claim. In dosage-based
states, claims for vaccines furnished by the SVP shall not be reimbursed
to providers other than the SVP, although other providers shall
be reimbursed for vaccine administration associated with administering
vaccines furnished by the SVP.
2.2
Per
Capita Based SVP Assessment Methodology
2.2.1 Under the per-covered life
assessment methodology for child vaccinations, each state calculates
a quarterly or annual assessment amount that would cover the average
patient in the state for state-supplied vaccination costs. The assessment
amount is calculated based on the number of covered lives reported
by insurers, vaccine prices that the state is able to get via bulk
orders through the CDC or distributors, and any operating and registry
expenses or statutory add-on amounts to cover vaccine stock and
availability of any state and federal funds. The state vaccine supply
costs are calculated by either a department within the state, a
non-profit state vaccine association, a state assessment board,
or outside organization, and invoiced to TRICARE for payment on
either a quarterly or annual basis in the form of an assessment
or vaccine purchasing pool fee.
2.2.2 The state (or designated authority)
will typically request the number of covered lives from each payor
in the state at a designated time(s) in the year, and then use that
data to calculate either an annual or quarterly assessment amount.
These assessment amounts will be provided to TRICARE on an annual
or quarterly basis.
2.2.3 Each individual SVP calculates
assessment amounts differently, and may also report their assessment
amounts in different ways. Consequently, the contractors shall establish
a process with each individual state assessment entity in their
respective regions to ensure accurate reimbursement. Such process
shall establish procedural protocols for the reporting and payment
of TRICARE beneficiaries covered under the SVP. Such a process shall
include, at a minimum, the designation of a liaison or contact person
within each of the state assessment entities who can provide a comprehensive
overview of their assessment process, addressing such questions
as:
• What
forms (online, survey or physical forms) or online websites are
to be used for reporting TRICARE per-covered lives;
• How assessments are
calculated;
• How
assessment fees are billed/invoiced;
• When assessments are
due and who is responsible for their calculation (the state assessment
entity or the payer);
• Where payments are
to be submitted (Vaccine Trust, Department of Insurance, Department
of Health, etc.);
• Whether
there are online assessment calculation worksheets available for
review and analysis); and
• When upcoming annual
assessment rates are posted for payers.
The contractor shall utilize
Addendum C which
describes the process for reimbursement of the SVPs, including SVPs
that supply adult vaccines, with the explicit understanding that
there are specific time intervals for reporting covered lives and
payment of SVP assessment amounts by state and these time frames
may be subject to change. This further supports the need for ongoing interactions
between the contractors and individual state assessment entities
in establishing up-to-date procedural protocols for the reporting
and payment of TRICARE beneficiaries covered under SVPs.
2.2.4 As additional
SVPs are added or as individual SVPs modify their procedures, the
contractor shall create processes in accordance with this paragraph,
Addendum C, and any new state procedures as
appropriate, to ensure reimbursement is made to the SVP in accordance
with this policy, to include applying the respective assessment
and capped reimbursement. The contractor shall establish protocols
for reporting and assessment payment with each individual state
SVP in its region.
2.2.5 DHA
will
provide appropriate population estimates that would be eligible
for the vaccine supply in the state. To accommodate this ongoing
reporting requirement, DHA will provide the contractors with the
number of TRICARE-reliants in each state subject to each capitated
per-covered life SVP on either a quarterly or annual basis in accordance
with the time frame used by each SVP. The term “reliants” refers
to a subset of TRICARE eligible beneficiaries who are dependent
on TRICARE for the coverage/reimbursement of vaccines under the
well-child and preventive benefits. All TRICARE Active Duty Family
Members (ADFMs) are considered to be reliant on TRICARE as their
primary form of insurance. DHA will estimate the percentage of TRICARE
non-Active Duty Dependent (ADD) reliants annually, and exclude any
non-ADDs who are not reliant on TRICARE as their primary form of
insurance in their covered lives population estimate. Since the
vast majority of Military Treatment Facility (MTF)/Enhanced Multi-Service
Market (eMSM)-Prime enrollees obtain their vaccines in the MTF/eMSM
setting versus a purchased care setting, the number of covered lives
reported to the SVPs will be limited to those child (age 0-18) reliants
that are not enrolled as MTF/eMSM-Prime. Active Duty Service Members (ADSMs)
under the age of 19 are also excluded from the reliant population
calculation. DHA will use a website for future correspondence of
the number covered lives with the contractors. The website is found
here:
https://health.mil/SVP.
2.2.6 The contractors
will correspond with each state SVP to report the number of TRICARE vaccine-eligible
covered lives on either an annual or quarterly basis through whichever
means the state decides (i.e., web portal, hard copy, online survey,
etc.).
2.2.7 The SVP assessment calculation process varies
by state and the contractor shall use the calculation method required
by each state and each respective SVP. For example, in some states
the TRICARE contractors may have to self-report their assessment
calculations reported during the assessment period, while in another
state, TRICARE may be asked to submit the number of covered lives
for the year or quarter, and the contractors will be automatically
invoiced for the total assessment amount in order to eliminate any
administrative burden on the Program.
2.2.8 There may also be differences
in when state assessment amounts are due for payment; i.e., some
states invoice payers quarterly, while other states invoice payers
annually. Again, the contractor shall comply with the reporting
period used by each state and each respective SVP.
2.2.9 Per the
statutory limitation, state SVP per-covered life assessment amounts
shall not exceed what would have otherwise been reimbursed under
the TRICARE benefit (i.e., the allowable charge reimbursement that
would otherwise be allowed for vaccines under the TRICARE well-child
and preventive benefits). As a result, TRICARE SVP reimbursements
are capped at the amount equal to the average amount for vaccinations
paid for each TRICARE reliant by TRICARE in states that do not offer SVPs.
The DHA will be responsible for calculating the average non-SVP
state per-reliant capped payment amount for vaccines for each quarter
using TRICARE allowed amounts and covered lives. The per capita
capped amount shall be determined by dividing the number of TRICARE
non-MTF/eMSM-Prime enrolled reliants age 0-18 in states that do
not offer SVPs by the total allowed amounts for vaccinations provided
to non-MTF/eMSM Prime enrolled TRICARE beneficiaries in states that
do not offer SVPs. The TRICARE per capita capped payment amounts
will be provided by DHA to the contractors on a quarterly or annual
basis depending on each respective SVPs reporting period. The contractors
shall compare the per capita SVP invoiced assessment amount to the
TRICARE per capita capped amount.
2.2.10 If the
state’s SVP per capita assessment amount is less than the TRICARE
per capita capped amount, the contractor shall reimburse the SVP
its invoiced amount. If, however, the SVP per capita assessment
amount is greater than the TRICARE per capita capped payment amount,
the contractors shall calculate the total TRICARE assessment amount
to be paid to the SVP for the time period using the TRICARE per
capita capped payment amount. The contractors shall communicate
with those states for which their assessment amount is higher than
the TRICARE per capita capped payment amount to ensure that they
understand the statutory restrictions on payment of SVPs under the
TRICARE Program. The ongoing verification process will ensure that
TRICARE is not paying more than it would under its standard allowable
charge methodology, as well as compliance with the statutory limitation.
2.3 Alternative
SVP Assessment Methodology Used By Massachusetts For Child Vaccines
2.3.1 Massachusetts
uses an alternative approach to fund its Pediatric Vaccine Trust
program. The trust is funded by all payers in the state who pay
for acute care and/or ambulatory surgical center services. The state’s
Pediatric Vaccine Trust assessment amount is known as the Pediatric
Immunization Program Assessment (PIPA). Each payer’s PIPA is calculated
as a percentage of their total paid amounts made to acute care hospitals,
hospital outpatient department facility charges, and freestanding Ambulatory
Surgery Center (ASC) facility charges during a three-month period
designated annually by the state. The PIPA percentage is determined
each year by the state by dividing the total amount collected for
the Massachusetts vaccine program by the total projected payments
from payers in the year. The PIPA payment amount is submitted to
the state by each payer, and then enters the Pediatric Vaccine Trust
fund.
2.3.2 In order to accommodate Massachusetts’ unique
assessment methodology, DHA will calculate the total TRICARE paid
amounts made to Massachusetts acute care hospitals, hospital outpatient
department facility charges, and freestanding ASC facility charges
for the three-month period designated by the Massachusetts Vaccine
Association to determine the annual PIPA amount. The total amounts
include all paid claim amounts for ADSMs, ADDs and non-ADDs less
than 65 years of age. This total amount includes government paid
amounts for patients with other health insurance, except payment
for Medicare eligible beneficiaries [e.g., dual eligibles under
TRICARE For Life (TFL)] and includes an estimate of Diagnosis Related
Group (DRG) capital and direct medical education payments made by
TRICARE to Massachusetts hospitals.
2.3.3 DHA will identify the appropriate
PIPA surcharge percentage for the time period (as designated by
the state), and multiply this percentage by the total TRICARE paid
amounts in the three month period. This amount will then be provided
to the contractor in order to be paid to the state.
2.4 Per Capita
Based SVP Adult Assessment Methodology
2.4.1 For states with current adult
state vaccine programs, the adult SVP assessment methodology is
similar to the child per-covered life assessment methodology noted
in
paragraph 2.2. The
contractor shall reimburse states with adult SVPs for all TRICARE
non-MTF/eMSM Prime ADFM and non-ADD beneficiaries, and all retired
beneficiaries over the age of 65 that have TRICARE as their primary
payer, and that are the appropriate age that is covered by the SVP,
on either an annual or quarterly basis. DHA will calculate the number
of covered lives in the state using the same methodology as in
paragraph 2.2 for
children. A state-specific adult TRICARE per capita amount will
be calculated because one state may provide different adult vaccines
than another state (for example, some adult SVPs supply the Shingles
vaccines while other adult SVPs do not). DHA will exclude any vaccines
that are reimbursed by Medicare for Medicare-eligible beneficiaries
in their calculation, if the state supplies vaccines to Medicare-eligible
beneficiaries. DHA will provide both the adult reliant population
and adult per capita capped payment amount information by state
to the contractors in order for them to report to each SVP at the
dates requested by the SVP.
2.4.2 The contractors shall identify
whether the SVP adult state-specific per capita assessment amount
that has been invoiced is greater than the calculated TRICARE adult
per capita capped payment amount. If the SVP per capita quarterly
assessment amount is less than the TRICARE per capita quarterly
capped payment amount, the contractors will pay the SVP invoiced
amount. If, however, the SVP per capita amount is greater than the
TRICARE per capita capped payment amount, the contractor will calculate
the total TRICARE assessment amount to be paid to the SVP for the
quarter by multiplying the number of TRICARE adult reliants in the
state by the TRICARE per capita adult state-specific capped payment
amount. The contractors will then be responsible for submitting
the appropriate payment to the SVP.
2.4.3 Each TRICARE contractor shall
establish processes with individual state assessment entities in
its region to ensure the accurate reporting and reimbursement of
TRICARE beneficiaries covered under adult SVPs.
2.5 Remittance
Of Per Capita Based (For Alternative) SVP Assessment Amounts
2.5.1 Remittance
of assessment fees will not require submission of an appropriate
claim form as prescribed in
32 CFR 199.7,
since payment is based on the anticipated proportional allocation
of state vaccine-eligible beneficiaries during a prescribed assessment
period; i.e., based on a projected number of state vaccine-eligible
beneficiaries reported by TRICARE contractors during an assessment
period. The assessment amount may either be self-initiated, where
the contractor simply multiplies a posted state assessment rate
by the number of state vaccine-eligible beneficiaries (TRICARE reliants)
under its coverage during a prescribed assessment period (e.g.,
on a quarterly or annual basis), or it may be calculated automatically
by the state assessment entity and invoiced to TRICARE for payment.
The contractors will have to set up internal payment procedures
to accommodate each of the SVPs under its jurisdiction; e.g., payment
of invoiced assessments via check or electronic transfer in accordance with
established payment protocols between each of the SVPs and TRICARE
contractors.
2.5.2 The contractors shall submit the SVP assessment
amounts to DHA for payment on a voucher in accordance with requirements
of the Contract Data Requirements List (CDRL) located in Section
G of the contract. The voucher shall be sent electronically to the
DHA Contract Resource Management (CRM) Office before payments are
released. The vouchers should contain the following information:
SVP assessment entity name, address, provider number, and the assessment
amount to be paid.