Vaccine Billing Reminder for Medicaid-Only Nursing Home Residents

(Dec. 23, 2024) The Department of Health (DOH) published a reminder for nursing homes regarding the responsible party for vaccine payment for Medicaid beneficiaries living in nursing homes who are not also covered by Medicare (i.e., non-duals). In its November Medicaid Update, the Department reiterated that vaccines, physician-administered drugs, over-the-counter (OTC) drugs, durable medical equipment (DME), and medical supplies are the responsibility of the nursing home. The November Medicaid Update article cited a June 2011 Special Edition (Nursing Homes/Residential Health Care Facilities Medicaid Prescription Drug Carve-Out) for more information. The November article also identified several edits that are applied to pharmacy claims that are the responsibility of nursing homes.

Although the November Medicaid Update article covered the Medicaid Assisted Living Program (ALP), along with nursing homes, LeadingAge NY believes this inclusion was erroneous. Vaccines typically are not the responsibility of the ALP. The association has reached out to DOH to discuss this further.

Nursing homes are reminded that most residents are dually eligible for Medicare and Medicaid. For those dually eligible residents in a Medicaid stay who have original (fee-for-service) Medicare coverage, nursing homes may bill Part B or Part D for vaccinations, depending on the vaccine. For those in a Medicare Advantage plan, vaccines are billed as directed by the plan. More information about billing for respiratory vaccines for residents with original Medicare coverage is available in this Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Fact Sheet. 

Contact: Karen Lipson, klipson@leadingageny.org