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
dosage-based assessment pricing grid for the state of Washington
may include an adjustment to the grid price to reflect a percentage
increase assessed by the Washington state vaccine association for
payers who do not complete settlement reports, as long as this assessed
percentage is consistent with the NDAA FY 2017 Section 719 limitations
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.