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 The contractor
shall establish a process with each individual state assessment
entity in their respective geographic area of responsibility to
ensure accurate reimbursement.
2.2.3.1 Each individual SVP calculates
assessment amounts differently, and may also report their assessment amounts
in different ways. 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
(e.g., Vaccine Trust, Department of Insurance, Department of Health);
• Whether there are online assessment
calculation worksheets available for review and analysis; and
• When upcoming annual assessment
rates are posted for payers.
2.2.3.2 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 The contractor
shall create processes, as additional SVPs are added or as individual
SVPs modify their procedures, 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.
2.2.5 The contractor
shall establish protocols for reporting and assessment payment with
each individual state SVP in its geographic area of responsibility.
2.2.6 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 Market/Military Medical Treatment
Facility (MTF) TRICARE Prime enrollees obtain their vaccines in
the Market/MTF 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 Market/MTF TRICARE
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.
2.2.7 The contractor shall 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 (e.g., web portal, hard copy, online survey).
2.2.8 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.
2.2.9 The contractor
shall comply with the reporting period used by each state and each
respective SVP. 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.
2.2.10 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-Market/MTF
TRICARE Prime enrolled reliants age 0-18 in states that do not offer
SVPs by the total allowed amounts for vaccinations provided to non-Market/MTF
TRICARE 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.
2.2.11 The contractor shall compare
the per capita SVP invoiced assessment amount to the TRICARE per
capita capped amount.
2.2.12 The contractor shall reimburse
the SVP its invoiced amount if the state’s SVP per capita assessment amount
is less than the TRICARE per capita capped 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.
2.2.13 The contractor 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 SVPs, the adult SVP assessment methodology is
similar to the child per-covered life assessment methodology noted
in
paragraph 2.2.
2.4.2 The contractor shall reimburse
states with adult SVPs for all TRICARE non-Market/MTF TRICARE 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.
2.4.3 The contractor
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.
2.4.3.1 The contractor shall pay the
SVP invoiced amount if the SVP per capita quarterly assessment amount is
less than the TRICARE per capita quarterly capped payment amount.
2.4.3.2 The contractor shall 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
if the SVP per capita amount is greater than the TRICARE per capita
capped payment amount.
2.4.3.3 The contractor shall then be
responsible for submitting the appropriate payment to the SVP.
2.4.4 The contractor shall establish
processes with individual state assessment entities in its geographic
area of responsibility 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.
2.5.2 The contractor shall set up
internal payment procedures to accommodate each of the SVPs under
its jurisdiction; i.e., payment of invoiced assessments via check
or electronic transfer in accordance with established payment protocols
between each of the SVPs and TRICARE contractors.
2.5.3 The contractors shall submit
the SVP assessment amounts to DHA for payment on a voucher in accordance
with reporting requirements (see DD Form 1423, Contract Data Requirements
List (CDRL), located in Section J of the applicable 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.