Seasonal Influenza Virus, Pneumococcal and Hepatitis B – FAQs

Does a Part B deductible or coinsurance apply to adult immunizations covered by Medicare?

Neither a Part B deductible nor coinsurance applies to the seasonal influenza virus or pneumococcal vaccines and their administration. The Part B deductible, plus the 20 percent Medicare coinsurance amount, applies to the hepatitis B vaccine for all dates of service prior to January 1, 2011, but will not apply for services on or after January 1, 2011.

If a beneficiary receives a seasonal influenza virus vaccination more than once in a 12-month period, will Medicare still pay for it?

Yes. Medicare pays for one seasonal influenza virus vaccination per influenza season; however, a beneficiary could receive the seasonal influenza virus vaccine twice in a calendar year for two different influenza seasons and the provider would be reimbursed for each. For example, a beneficiary could receive a seasonal influenza virus vaccination in January 2011 for the 2010-2011 influenza season and another seasonal influenza virus vaccination in November 2011 for the 2011-2012 influenza season and Medicare would pay for both vaccinations.

Are HCPCS codes Q2035 and Q2039 payable by Medicare?

Effective for claims with dates of service on or after October 1, 2010, Q2035 and Q2039 are payable by Medicare. However, the codes will not be recognized by the Medicare claims processing systems until January 1, 2011. Since no national payment limits are available for Q2035 or Q2039, payment limits will be determined by the local claims processing contractor.

Will Medicare pay for the pneumococcal vaccination if a beneficiary is uncertain of his or her vaccination history?

Yes. If a beneficiary is uncertain about his or her vaccination history in the past five years, the vaccine should be given and Medicare will cover the revaccination. If a beneficiary is certain that more than five years have passed, revaccination is not appropriate unless the beneficiary is at highest risk.

Does Medicare cover the hepatitis B vaccine for all Medicare beneficiaries?

No. Medicare provides coverage for certain beneficiaries at intermediate to high risk for the hepatitis B virus (HBV). These individuals include workers in health care professions who have frequent contact with blood or blood-derived body fluids during routine work, those with End-Stage Renal Disease (ESRD), and persons who live in the same household as an HBV carrier. There are other situations which could qualify a beneficiary as being at intermediate or high risk of contracting HBV.

Can the seasonal influenza virus, pneumococcal, and hepatitis B vaccines all be roster billed?

No. Only the seasonal influenza virus and pneumococcal vaccines are eligible for roster billing. Roster billing does not apply to the hepatitis B vaccine.

For more details please visit: https://www.cms.gov/MLNProducts/downloads/qr_immun_bill.pdf