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Home Health Immunization Reimbursement

Vaccines

The reimbursement home health agencies (HHAs) receive for the influenza or pneumonia vaccine is calculated on a reasonable cost basis. Claim reimbursement is based on the amount the HHA bills and the Part B reimbursement percentage (Interim Rate) that is set for them, based on past Medicare cost report information. For example, a provider who bills $25.00 for the flu vaccine and has a reimbursement percentage (Interim Rate) of 0.90 (90 percent) would be reimbursed $22.50. The cost reimbursement is then calculated on the Medicare cost report when it is submitted at the agency's fiscal year end. This reimbursement is subject to the lower of cost or charges as calculated on Worksheet C and D. For example, if the provider's reimbursable cost for influenza vaccines is $2,000, and their charges (per the Provider Statistical and Reimbursement Report) are $1,500, they will be limited to $1,500 of reimbursement.

Shot Administration

HHAs receive reimbursement for administering flu or pneumonia shots under the Outpatient Prospective Payment System (OPPS) Ambulatory Payment Classification (APC) code 0350 that is assigned to HCPC codes G0008 and G0009. The reimbursement amount is adjusted for the geographic area where the vaccine was provided and other factors. Due to the adjustments under OPPS, the actual payment amount your HHA receives could be more or less than the calendar year reimbursement amount for APC code 0350. CGS is unable to provide the actual amount you will receive for the flu or pneumonia shot administration since this is based on OPPS processing.

Additional Resources

Updated: 10.02.17


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