Effective July 1, 2025, CMS implemented significant changes to Medicare Part B preventive vaccine billing for Federally Qualified Health Centers (FQHCs). These updates expand billing flexibility while introducing new cost reporting considerations for FQHC providers.
Expanded Billing Flexibility
Beginning July 1, 2025, FQHCs should bill at the time of service for the four cost-settled Medicare preventive vaccines (pneumococcal, influenza, hepatitis B, and COVID‑19) and their related administration for original Medicare beneficiaries. These requirements do not affect existing vaccine billing practices for Medicare Advantage enrollees.
Notably, these vaccines and their administration may be billed with or without a qualifying visit.
Payment Methodology
At the time of service, these preventive vaccines will be reimbursed consistent with Medicare Part B vaccine payment rules:
- Vaccine products will be paid at 95% of Average Wholesale Price (AWP).
- Vaccine administration will be reimbursed according to the Medicare Part B National Fee Schedule for vaccine administration adjusted for geographic location.
Vaccines and their administration must be billed on a CMS-1450 (UB‑04) claim form.
Cost Report Reconciliation & PS&R Visibility
Although payment is made at the time of service, FQHCs will reconcile payments received for these vaccine products and administration with the actual costs incurred through the annual Medicare cost report. Payments for these preventive vaccines and counts of the vaccines billed will be reflected on the Provider Statistical & Reimbursement (PS&R) Report, Type 772, which is used in the completion of Worksheet B-1 of the Medicare cost report, making accurate time of service billing and ongoing cost tracking critical for proper identification and reconciliation of vaccine-related Medicare payments.
What This Means for FQHCs
These vaccines need to be billed at time of service to enable the vaccines given to original Medicare beneficiaries to be settled to cost. These changes are expected to improve cash flow through immediate reimbursement while increasing the importance of coordination between billing and finance functions. FQHCs should concurrently review charge capture workflows and vaccine cost tracking practices to help ensure accurate time of service billing and complete reconciliation through the Medicare cost report.
For more information on Medicare billing for FQHCs and other healthcare updates, please reach out to a professional from our Community Health Centers (CHCs) team.