Washington Universal Childhood Vaccine Program

This is an update provided jointly by the Washington State Department of Health, Washington State Medical Association, Washington Chapter of the American Academy of Pediatrics and the Washington Academy of Family Physicians on the Universal Childhood Vaccine Program.

On March 23, 2010 Gov. Chris Gregoire signed a law that keeps the universal Washington Childhood Vaccine Program from ending state-supplied vaccine for children covered by private health insurance due to state funding cuts. The law requires private health plans and other payers (“payers”) to pay the state a Dosage Based Assessment (“DBA”), an amount based on the cost of state-supplied vaccines given to the children they cover. The law also creates the Washington Vaccine Association (“Vaccine Association”) to administer the DBA payments from payers to the state.

On April 2, 2010, after an evaluation process involving health care providers (“providers”), payers and the Washington State Department of Health, the Vaccine Association’s board of directors formally adopted an interim data tracking and reporting procedure that will help determine how much each payer must pay to the state. Of the many methods considered, it was determined that a method based upon existing payment mechanisms was the most expedient way providers, payers (both within and outside Washington) and the Vaccine Association could meet the new law requirements by May 1, 2010 when state funding ends. The interim procedure uses claim forms as the mechanism to collect state-supplied vaccine data, and it requires both providers and payers to make changes to the way they submit and handle vaccine-related claims.

How and why was this DBA form method chosen over other methods?
Every method suggested by providers and payers was evaluated to see how well it addressed stakeholder concerns and whether it was feasible to implement the method by May 1, 2010. Providers, payers and the nonprofit Vaccine Association all wanted to avoid added administrative cost or complexity. The payers, which are now subject to an assessment based on their members’ vaccine usage, needed a method that fairly and equitably collects payments from all payers, including those based outside of Washington who provide coverage to a significant number of children in the state. The state also needed the method to capture payments from all affected payers within and outside Washington to ensure the long term financial viability of the Childhood Vaccine Program. Providers, who benefit from the cost-free vaccines and single distribution channel, expressed the strong desire to retain existing processes and administrative simplicity. Public health wanted broad provider participation to ensure access to vaccines for children and increase immunization rates.

The DBA form procedure outlined above was the only one that could use existing processes and effectively capture payments from out of state payers by May 1, 2010. Combining the DBA and administration charges in a single claim form using an SL modifier would mimic the current practice of some providers, but the method could not be easily coordinated with out of state payers who would not know how to process the vaccine charges to the Vaccine Association. A list bill or roster method would create costs for providers and the Vaccine Association because providers would need to render new reports and data, and the Vaccine Association would have to convert that report into a DBA form for the payer. These changes could not be implemented by May 1, and this method still would not effectively capture out of state payers. Capturing data through the Child Profile Immunization Registry was also considered, but the electronic process and modification to include health insurance data in the Immunization Registry could not be implemented by May 1.

What if a practice cannot submit separate DBA form by May 1, 2010?
If a provider does not yet have the capability to submit the separate DBA form by May 1, 2010, the provider may continue to submit a single claim form with both the state-supplied vaccine and administration codes until June 1, 2010. This type of submission must include:

1. Administration code for the administration of the vaccine, office call or other charges (box 24D). The payer will reimburse the provider for these costs as before.
2. Appropriate CPT code for the state-supplied vaccine given (box 24D). The SL modifier MUST be included after the vaccine CPT code.
3. The charge for the vaccine must indicate a penny or zero charge.

Is there anything different about vaccine ordering and eligibility screening?
No. The Childhood Vaccine Program procedures for ordering, receiving, administering, and documenting vaccines remain the same. Providers will be able to order all ACIP recommended vaccines, including HPV vaccine, from the state for all children under 19 years of age. Providers will also still have to screen for and document VFC-eligibility.

Will these changes affect the way the practice bills for vaccine services provided to Medicaid patients?
No, practices should continue to follow billing guidance provided by the state Medicaid program.

What about privately purchased vaccine?
Providers, patients and communities all benefit from the Washington Childhood Vaccine Program. The program will have the best chance of success if providers participate and obtain vaccines through the state.

If a practice chooses not to participate in the state program and chooses instead to purchase vaccines privately, the practice must:

• Front the cost for the private purchase of vaccines and consider purchasing insurance for the vaccine,
• Contact each health plan separately to determine each plan’s reimbursement policy for privately purchased vaccine, and
• Manage two separate vaccine inventories – one for vaccines from the state for VFC-eligible patients and one for vaccines that are privately purchased.

Where can providers go for the most updated information on the Childhood Vaccine Program?

• More information is available online at http://www.doh.wa.gov/cfh/Immunize/providers/universal.htm.
• Additional questions not addressed in the website above can also be sent to universalchanges@doh.wa.gov.
• In addition, the Vaccine Association will host a Webinar for providers’ office staff on April 23, 2010 from 11:00 a.m. to 12:30 p.m. to help offices implement the DBA data tracking and reporting procedures. As soon as it becomes available, registration instructions and dial-in information will be posted on the Association’s website: www.WAvaccine.org. Please assign a staff member to look for this information.