NC Coverage Criteria Changes

1. NC Coverage Criteria Changes Please dial 919-715-0769 for the audio. Changes to NCIP’s coverage of vaccines for insured and under insured patients. Brandon C. L. Rector MSW Vaccine Distribution Manager

2. 10 – 1 - 2012 • Elimination of Vaccine for Insured Patients: With very few exceptions, which are outlined in our NCIP Coverage Criteria, fully insured patients of any age will no longer be eligible for any vaccines provided by the NCIP. • Serving Under Insured Children: Private providers will no longer be able to provide VFC (state-supplied) vaccine to underinsured children. Underinsured children will be able to receive VFC vaccine at FQHCs, RHCs, and LHDs, and a few select private providers meeting specific geographic criteria to improve access to vaccines. For FQHC’s, RHCs and LHDs, business will continue as usual.

3. Elimination of Vaccine for Insured Patients All vaccines currently offered universally for children will be available only for VFC-ELIGIBLE children. All vaccines currently available for adults (persons aged 19 years and above) will be available for UNINSURED adults only. Adults with Medicaid and Under Insured Adults DO NOT qualify for state-supplied vaccines.

4. We will continue to cover … Uninsured Adults at any NCIP Provider • Hepatitis B for those who began before 19 • Meningococcal for 1st year college students in dorms • 2 doses of MMR for those entering college • Td for those entering college • Tdap Uninsured Adults at the Local Health Department • Twinrix • Hepatitis B for refugees • 1 dose of MMR • 2 doses of MMR for women of childbearing age (NEW CATEGORY) • Tdor Tdap (as indicated) *Td is also available for wound management for uninsured patients at NC Emergency Departments.

5. Exceptions • DT will remain universal. • Hepatitis B birth dose • 2012-13 Influenza Vaccine

6. Exceptions at Health Departments Only • Close contacts of a person with an acute or chronic hepatitis B infection (any age) • Post-exposure

7. Under Insured The following children are considered underinsured if: • they have commercial (private) health insurance but the coverage does not include vaccines*, • their insurance covers only selected vaccines (in this scenario, only non-covered vaccines may be provided through VFC), • or their insurance caps vaccine coverage at a certain amount – once that coverage amount is reached, these children are categorized as underinsured.

8. Insured • Has a co-pay • Has a deductible • Health Choice • Seeing a doctor outside of network • Insurance does not cover the full cost of vaccination Under Insured • No wellness (or preventative services) plan • Does not cover vaccines • Does not cover specific vaccines (ex. HPV for males) • Met a wellness cap * American Indian, Alaskan Native, and Medicaid patients are always eligible for VFC vaccine regardless of insurance coverage. Providers should use the supply of vaccine that provides the least burden for your patient.

9. Screening Error What if a patient reports themselves as fully insured, but you later find out that they are, in fact, underinsured? • Undeputized Providers MAY NOT pay back their private supply with state-supplied vaccine. • Undeputized Providers may bill the patient, but should educate the patient that they could receive vaccines at no cost in the future. • Undeputized Providers may choose to absorb the cost. *Other screening errors may still be corrected by replacement from the correct inventory and documentation on the Borrowing & Replacement Form

10. Supply Management Vaccine that providers have on hand prior to October 1 may continue to be used according to the existing NCIP Coverage Criteria document (dated July 24, 2012) until that vaccine expires or until December 31, 2012, whichever comes first. • Created to minimize vaccine loss due to expiration and maximize the number of patients vaccinated. • Does not apply to 2012-2013 flu vaccine. • First ever expiration date on a Coverage Criteria document. Mark your calendars for January 1. • There should be no reason to increase order amounts in September. Continue ordering according to usage.

11. RESOURCES MEMO http://www.immunize.nc.gov/providers/memos.htm FAQ http://www.immunize.nc.gov/PDFs/NCIP%20programmatic%20Changes%20for%20all%20providers.pdf COVERAGE CRITERIA http://www.immunize.nc.gov/providers/coveragecriteria.htm Brandon Rector 919-707-5553 brandon.rector@dhhs.nc.gov Help Desk: 1-877-873-6247