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.