The Commonwealth of Massachusetts Executive Office of Health and Human Services

MASSHEALTH FLU AND ADULT VACCINE PROGRAM FOR LOCAL PUBLIC HEALTH PROVIDERS (Program Instructions)

The Commonwealth of Massachusetts Executive Office of Health and Human Services (EOHHS) Office of Medicaid (MassHealth), through the MassHealth Flu and Adult Vaccine Program for Local Public Health Providers (MassHealth Program), continues to accept applications from eligible Local Public Health Departments (LPHDs) and Public School Districts (PSDs) for the provision of 1) influenza (flu) vaccines, and for LPHDs, 2) adult vaccines to eligible MassHealth members. The Program Instructions include specific requirements for LPHDs and PSDs that may vary based on the two program components.

MassHealth Flu and Adult Vaccine Provisions

To be eligible to enroll in any component of the MassHealth Program, LPHDs and PSDs must be actively enrolled (annually enroll) in the Massachusetts Department of Public Health (MDPH) Immunization Program. To enroll in the MDPH Immunization Program, please call 617-983-6828.

LPHDs are eligible to enroll in both the flu and adult components of the MassHealth Program (details on the adult vaccine component are provided below). PSDs are eligible to enroll only in the flu component of the Program.

To confirm eligibility for applying to the MassHealth Program, please call MassHealth at (617) 847-3130.

For LPHDs and PSDs enrolled in the MDPH Immunization Program, MDPH provides flu vaccines at no cost for children up to and including age 18. For MassHealth members age 19 and older, LPHDs and PSDs have to purchase the respective vaccines and can bill MassHealth for the cost of the vaccine themselves, as well as the administration of the vaccines. LPHDs and PSDs can bill MassHealth for the administration of state-supplied vaccines to MassHealth members but not for the state-supplied vaccines themselves.

Note: For a MassHealth member not enrolled in a Managed Care Organization (MCO), EOHHS will pay the eligible LPHD or PSD for non-MDPH supplied vaccine and vaccine administration at fee-for-service rates. For a MassHealth member enrolled in an MCO, the LPHD or PSD should bill and be paid in accordance with the MCO’s reimbursement policies; therefore claims should be sent to the respective MCO.

Adult vaccines covered by the MassHealth Program

In addition to flu vaccines, LPHDs can receive payments for the purchasing and administration of adult vaccines recommended by the U.S. Centers for Disease Control’s

of 5 Advisory Committee on Immunization Practices (ACIP) including: hepatitis A; hepatitis B; hepatitis A and hepatitis B (HepA-HepB); human papilloma virus (HPV); measles, mumps, and rubella (MMR); meningococcal conjugate; meningococcal polysaccharide; pneumococcal conjugate; pneumococcal polysaccharide; tetanus toxoid adsorbed; tetanus and diphtheria toxoids, and acellular pertussis (Tdap); varicella; and zoster (shingles).

Note: PSDs are not eligible to bill MassHealth for adult vaccines.

General Program Requirements

The following specifications must be fulfilled by LPHDs and PSDs to participate in either component of the Program. Section 1. The LPHD or the PSD providing vaccine services must be located in Massachusetts. Section 2. The LPHD or the PSD must be enrolled in the MDPH Immunization Program, and must administer flu, and for LPHDs adult vaccine services in a clinic open to the public in accordance with the Guidelines for Compliance with Federal and State Vaccine Administration Requirements. To enroll in the MDPH Immunization Program call 617- 983-6828. MDPH requires annual re-enrollment in the Immunization Program which must be maintained in order to remain enrolled in the MassHealth Program. Section 3. LPHDs must complete the MassHealth Flu and Adult Vaccine Program Provider Contract. PSDs must complete the MassHealth Flu Vaccine Provider Contract. Note: LPHDs currently enrolled in the flu component of the Program that wish to receive payment for the provision of adult vaccines must sign the Amended and Restated MassHealth Flu and Adult Vaccine Program Provider Contract. Section 4. LPHDs and PSDs are permitted to subcontract their vaccine purchasing and administration services. Although LPHDs and PSDs might have subcontracts with Visiting Nurse Associations (VNAs) or other entities that are enrolled in the MDPH Immunization program, the LPHDs and PSDs must still enroll in the MDPH Immunization Program, contract with MassHealth, and submit claims to MassHealth. LPHDs and PSDs will be issued a check upon approval of their claims, and they are responsible for arranging payments to their subcontractors. LPHDs and PSDs are responsible for overseeing the proper administration of the vaccines by the subcontractors. LPHDs and PSDs will be held responsible for the protection of privacy data according to Section II, Paragraphs I and J of the Program Contract; therefore, they must put in place a privacy data provision in any subcontract agreement. Section 5. LPHDs and PSDs must comply with all laws and regulations, contract provisions, rules, provider bulletins, and billing instructions applicable to participation in MassHealth.

On an annual basis, MassHealth e-mails enrollment and informational packets to LPHDs and PSDs that participate in the MDPH Immunization Program. However, providers are responsible for monitoring the Commonwealth of Massachusetts’ eProcurement / Purchasing System (COMMBUYS) and obtaining the most updated documentation and notices posted on COMMBUYS. Page 2 of 5 The enrollment packets include the following documents.

1. MassHealth Flu and Adult Vaccine Program Instructions (also posted on COMMBUYS) 2. MassHealth Flu and Adult Vaccine Program Provider Application. Please note: If you have not received the application packet, you may request it at (617) 847-3130 and confirm your eligibility for enrollment. 3. LPHDs and PSDs must complete the appropriate MassHealth Vaccine Program Provider Contract. You may request it at (617) 847-3130. (LPHDs already enrolled in the flu component of the Program, should sign the Amended and Restated MassHealth Flu and Adult Vaccine Program Provider Contract.) 4. MassHealth Flu and Adult Vaccine Program Provider Application Checklist. 5. List of flu procedure codes and rates for 2014-2015 (also posted on COMMBUYS) 6. For LPHDs only, a list of adult vaccine procedure codes and rates for 2014-2015 (also posted on COMMBUYS) 7. Data Collection Form (DCF) 8. National Provider Identifier (NPI) Supplement 9. Trading Partner Agreement (TPA) 10. Federally Required Disclosures Form (PE-FRD) with the exception of Section IV. C, Business Transactions 11. Massachusetts Substitute W-9 Form: Request for Taxpayer Identification Number and Certification (Form MA-W-9) 12. Authorization for Electronic Funds Transfer of MassHealth Payments (EFT-1) Note: LPHDs must have the municipality’s treasurer sign the W-9 and the EFT-1 forms. PSDs must have the school district’s appropriate administrator sign the W-9 and EFT-1 forms.

The website for the MassHealth Flu and Adult Vaccine Program for Local Public Health Providers is www.mass.gov/eohhs/gov/newsroom/masshealth/providers/masshealth-flu- and-adult-vaccine-program.html

LPHDs and PSDs must complete and sign all applicable documents and submit them to the following address.

MassHealth Customer Service Attention: Provider Enrollment and Credentialing P.O. Box 9162 Canton, MA 02021-5213

Once an LPHD or PSD is enrolled in the MassHealth Program, it does not need to renew its provider contract unless instructed by MassHealth. However, MDPH Immunization Program enrollment must be renewed on an annual basis in order to maintain continued eligibility for the MassHealth Program and in order to have no interruption in billing. Page 3 of 5 LPHDs enrolled only in the flu component of the Program are strongly encouraged to sign the Amended and Restated MassHealth Flu and Adult Vaccine Program Provider Contract in order to be enrolled in the MassHealth adult vaccine component of the Program.

Payment for Covered Services The lists of codes covered for the cost and administration of the flu and adult vaccines have been updated. Please ensure that you are using the most updated procedure codes and rates for 2014-2015 that are currently based on the following publication: EOHHS 101 CMR 317.00 MEDICINE (formerly 114.3 CMR 17.00) adopted on April 12, 2013. Please refer to the 317.03: General Rate Provisions section.

Please note the following relative to the procedure codes for 2014-2015:  Administration procedure codes are age-based.  There may be a difference in the payment rate if the vaccine is State Supplied (“SL” modifier).  I.C. stands for “individual consideration”: payment will be based on the manufacturer’s invoice for the number of doses and the price per dose.

Note: Providers are responsible for keeping up to date with codes and covered vaccines. If there are any changes to the coverage or type of vaccines, the information will be posted on COMMBUYS.

Billing Provisions LPHDs and PSDs can use the following options for claims submission:  Direct Data Entry (DDE)  Subcontract this service to a vendor/billing agent.

Providers must submit claims to MassHealth within 90 days of the service date. Providers that choose to use a billing vendor should ensure that the vendor submits the providers’ claims on a timely basis.

Important Note for MassHealth members enrolled in MCOs LPHDs and PSDs should record, share, and report the member’s MassHealth ID and type of coverage in addition to the name, date of birth, flu and/or adult vaccine name(s) and date(s) of service.

Reporting Requirements To report administration of the influenza vaccine to a MassHealth member so that the member can share this information with his/her primary care provider when sharing such information is permissible under state and federal regulations. At a minimum, provide the member with a document that includes the following data elements and encourage the member to share this information with his/her provider: 1. Member’s name 2. Member’s date of birth 3. Vaccine name Page 4 of 5 4. Date of administration Posting on COMMBUYS The Program enrollment announcement has been distributed using the Commonwealth of Massachusetts’ eProcurement/Purchasing System called COMMBUYS. Applicants are solely responsible for completing and submitting the required MassHealth Flu Vaccine Program enrollment documents that are identified in this announcement and for checking COMMBUYS for any addenda or modifications that may subsequently be made to the enrollment documents.

Questions about the MassHealth Flu and Adult Vaccine Program If you have any questions about the MassHealth Program, please contact MassHealth Customer Service at 1-800-841-2900 (Hours: Monday–Friday, 8:00 a.m.–5:00 p.m.) or send an e-mail to [email protected].

Questions about the MDPH Vaccine Program If you have clinical questions about vaccines or vaccine-preventable diseases, please call the MDPH Epidemiology and Immunization Unit at 617-983-6800.