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Coverage of the Administration at Home for Pneumococcal, Influenza, Hepatitis B, and COVID-19 Vaccination for Medicare Advantage Members (Retroactively Effective to 1/1/2024)


Purpose

To communicate the expansion of  the administration at home procedure ​code to include additional vaccines (i.e., pneumococcal, influenza, hepatitis B) that can be administered in a home setting. ​

Background

To promote vaccination of home-bound individuals,​ CMS allowed additional reimbursement for when certain va​ccines are provided in the ​individual's home. 

Coverage Statement

MEDICALLY NECESSARY


When pneumococcal, influenza, hepatitis b, and/or COVID-19 vaccines are medically necessary, a home visit for the sole purpose of administration of pneumococcal, influenza, hepatitis B, and/or COVID-19 vaccines is considered medically necessary and, therefore, covered as a preventive service for individuals who meet either of the following criteria:​

  • ​The individual has difficulty leaving the home to get the vaccine, which could mean any of these: 
    • A condition, due to an illness or injury, that restricts their ability to leave home without a supportive device or help from a paid or unpaid caregiver
    • A condition that makes them more susceptible to contracting a disease
    • Generally unable to leave the home, and if they do leave home, it requires a considerable and taxing effort 
  • The individual i​s hard ​to reach because they have a disability or face clinical, socioeconomic, or geographical barriers to getting a vaccine in settings other than their home. These individuals face challenges that significantly reduce their ability to get vaccinated outside the home, such as challenges with transportation, communication, or caregiving​.​

 

NOT ELIGIBLE FOR SEPARATE REIMBURSEMENT​


For individuals currently receiving home care services, administration of pneumococcal, influenza, hepatitis B, and/or COVID-19 vaccines are not eligible for separate reimbursement consideration from the home care visit. ​


Coding

​M0201

02/26/2024