Updated COVID-19 Vaccine Counseling Coverage

  • Guidance is also available in Portable Document Format (PDF)

Updated 5/3/2023

Changes are highlighted in yellow.

Effective May 12, 2023, New York State (NYS) Medicaid fee-for-service (FFS), Medicaid Managed Care (MMC) Plans [including mainstream MMC Plans, Health and Recovery Plans (HARPs), and HIV (Human Immunodeficiency Virus) Special Needs Plans (SNPs)], will continue to provide reimbursement for Coronavirus Disease 2019 (COVID-19) vaccine counseling to Medicaid FFS and MMC plan members under age 21 to encourage the administration of the COVID-19 vaccine.

Effective May 12, 2023, COVID-19 vaccine counseling for Medicaid FFS and MMC [including mainstream MMC Plans, Health and Recovery Plans (HARPs), and HIV (Human Immunodeficiency Virus) Special Needs Plans (SNPs)] members age 21 and older will no longer be reimbursed as a stand alone service. Reimbursement for COVID-19 vaccine counseling is included in the Evaluation and Management (E&M) visit for Medicaid FFS and MMC Plan members age 21 and older.

MMC Plans must continue to cover COVID-19 vaccine counseling for MMC members under age 21. MMC Plans must continue to reimburse providers at no less than the Medicaid FFS rate until further notice.

The following coverage criteria supersedes the coverage criteria published in the NYS November 2021 Medicaid Update Article, titled COVID-19 Vaccine Counseling Coverage.

The provider types listed below may bill for COVID-19 vaccine counseling:

  • Physicians
  • Nurse Practitioners (NPs)
  • Licensed Midwives
  • Pharmacists
  • Article 28 clinics billing ordered ambulatory
  • Federally Qualified Health Centers (FQHCs)
  • Other qualified rate-based providers

Updated Coverage Criteria

Providers may bill for COVID-19 vaccine counseling provided to Medicaid members under age 21 after May 11, 2023:

  • as a stand-alone service when all the criteria specified in this guidance are met and documented.
  • in addition to an Evaluation and Management (E&M) or Well Child Visit when all the criteriaof the vaccine counseling visit specified in this guidance are met and documented, in addition to all of the necessary components of the E&M/Well Child visit.
  • whether or not a COVID-19 vaccine is administered during the encounter.
  • using the Medicaid enrolled child’s Client Identification Number (CIN) when counseling is provided to a parent, caregiver, or guardian for the benefit of the child, with or without the child present during the counseling session.
  • for up to four counseling visits per vaccine dose recommended by the Centers for Disease Control and Prevention (CDC), when the member has not received and does not have an appointment to receive, the recommended dose, up to a total of 12 visits per member per year.

Additional information regarding COVID-19 vaccines recommended by the CDC can be found on the CDC web page. Qualified providers may provide up to four pre-decisional counseling visits for each dose recommended by the CDC, including booster doses, up to a total of twelve visits per year. Members receiving counseling on an initial dose or subsequent dose, including boosters, must not have already received the dose and must not already have an appointment to receive the dose.

The NYS Medicaid program provides reimbursement for medical care and services only after all other resources available for payment have been reviewed and used. If a Medicaid member has third-party insurance coverage, the benefits of that coverage must fully be used before billing the NYS Medicaid program. Providers should always ask Medicaid members if they have other or third-party coverage to ensure the proper coordination of benefits. Providers who already receive payments from another source for COVID-19 vaccination counseling (e.g., the New York City COVID-19 Vaccine and Counseling outreach program) are not eligible for reimbursement from Medicaid. Medicaid is the payor of the last resort; federal regulations require that all other available resources be used before Medicaid considers payment.

The COVID-19 vaccine counseling session must be documented in the medical or pharmacy record and must include the following:

  • confirming that the patient is not currently – "up to date" with COVID-19 vaccine dosing, as recommended by the CDC per the CDC "Stay Up to Date with Your Vaccines" web page.
  • confirming vaccination status in the New York State Immunization Information System (NYSIIS) for providers in NYS, outside of New York City (NYC), or Citywide Immunization Registry (CIR) for providers in NYC, whenever possible;
  • confirming the patient does not already have an appointment scheduled to receive an initial or subsequent dose as recommended by the ACIP/CDC;
  • confirming patient consent, or consent of the parent, guardian, or caregiver (if appropriate) to receive the counseling.
  • the reasons expressed by the patient, parent, or caregiver for vaccine hesitancy;
  • strongly recommending the COVID-19 vaccination (unless medically contraindicated, in which case the counseling session is not billable).
  • counseling the patient, along with their parent, guardian, or caregiver (if appropriate) on the safety and effectiveness of COVID-19 vaccines.
  • answering any questions the patient or parent, guardian, or caregiver has regarding COVID- 19 vaccination.
  • counseling the patient, along with their parent, guardian, or caregiver (if appropriate) for a minimum of eight minutes.
  • arranging for vaccination or providing information on how the patient can get vaccinated for COVID-19.

Physicians, Nurse Practitioners, and Licensed Midwives

A provider submitting professional claims should bill Current Procedural Terminology (CPT) code "99429", Unlisted Preventive Medicine Service, for reimbursement of COVID-19 vaccination counseling.

HCPCS Code Code Description Fee
99429 Unlisted Preventive Medicine Service $25.00

Pharmacists

A pharmacist providing COVID-19 vaccination counseling should bill using the National Council for Prescription Drug Programs (NCPDP) D.0 claim format as outlined below.

NCPDP D.0 Claim Segment Field Value
436-E1 (Product/Service ID Qualifier) Enter the value of "09" [Healthcare Common Procedure Coding System (HCPCS)], which qualifies the code submitted in field 407-D7 (Product/Service ID) as a procedure code*
407-D7 (Product/Service ID) Enter "99429"
Pharmacy Provider Segment Field Value
444-E9 (Pharmacist ID) Enter Pharmacist National Provider Identifier (NPI) number
Prescriber Segment Field Value
411-DB (Prescriber ID) Please leave field blank

*COVID-19 vaccine billing guidance can be found on the NYS DOH "COVID-19 Guidance for Medicaid Providers" web page.

Article 28 Clinics Billing Ordered Ambulatory

Article 28 clinics, including hospital outpatient departments (HOPDs) and Diagnostic and Treatment Centers (D&TCs), should bill an ordered ambulatory claim for COVID-19 vaccine counseling using the CPT code "99429".

HCPCS Code Code Description Fee
99429 Unlisted Preventive Medicine Service $25.00

Federally Qualified Health Centers

FQHCs should bill their prospective payment system (PPS) rate when providing COVID-19 vaccination counseling, but FQHCs are encouraged to perform other evaluation and management, or clinical services included within the PPS rate in connection with the counseling session.

Other Qualified Rate-Based Providers

The rate-based provider types listed below may bill for COVID-19 vaccination counseling using rate code "5521" with Category of Service (COS) code "0268" when provided to Medicaid members under age 21:

  • Skilled Nursing Facilities (SNFs)
  • Certified Home Health Agencies (CHHAs)
  • Hospice
  • Adult Day Health Care (ADHC)
  • Inpatient Hospitals
  • Assisted Living Programs (ALPs)
  • Voluntary Foster Care Agencies (VFCAs)
  • Article 16 facilities/clinics (Office for People with Developmental Disabilities)
  • Article 31 facilities/clinics (Office of Mental Health) – NOTE: Article 31 facilities/clinics would bill rate code "5521" using COS codes "0160" or "0268".
  • Article 32 Facilities/Clinics (Office of Addiction Services and Supports) – NOTE: Article 32 facilities/clinics would bill rate code "5521" using COS code "0160", "0268" or "0287".
Rate Code Rate Code Description Fee
5521 COVID-19 VACCINATION COUNSELING – EIGHT-MINUTE MINIMUM $25.00

COVID-19 Vaccine Counseling Provided via Audio-Only (Telephonic) Telehealth

NYS Medicaid covers audio-only COVID-19 vaccine counseling visits for NYS Medicaid members when all the following conditions are met:

  • audio-visual telehealth is not available to the patient due to lack of patient equipment or connectivity (see “VIII. Options to Support Members with Limited or Lack of Access to Devices and Services” on page 17 of this issue and “IX. Useful Links” on page 19 of this issue, for connectivity resources) or audio-only is the preference of the patient;
  • the provider must make either audio-visual or in-person appointments available at the request of the patient;
  • the service can be effectively delivered without a visual or in-person component, unless otherwise stated in guidance issued by the NYS DOH (this is a clinical decision made by the provider); and
  • the service provided via audio-only visits contains all elements of the billable procedures or rate codes and meets all documentation requirements as if provided in person or via an audio-visual visit.

The following provider types must follow the guidance provided below when billing for COVID-19 vaccine counseling via audio-only (telephonic) telehealth:

  • Physicians, NPs, and licensed midwives should bill the CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth.
  • Article 28 clinics (including HOPDs and D&TCs) should bill an ordered ambulatory claim using the CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth.
  • Pharmacists may provide audio-only (telephonic) telehealth counseling and must document the counseling in the pharmacy record with the claim that is submitted for CPT code "99429".
  • Other Qualified rate-based providers listed above should bill using rate code "5521" with CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth.
  • FQHCs should bill the off-site rate code "4012" with CPT code "99429" appended with the GQ modifier to indicate the service was provided via audio-only (telephonic) telehealth.

Questions and Additional Information:

  • FFS claim questions should be directed to the eMedNY Call Center at (800) 343-9000.
  • FFS coverage and policy questions should be directedto the Office of Health Insurance Programs (OHIP) Division of Program Development and Management (DPDM) by telephone at (518) 473-2160 or by email at FFSMedicaidPolicy@health.ny.gov.
  • FFS Pharmacy coverage and policy questions should be directed to the Medicaid Pharmacy Policy Unit by telephone at (518) 486-3209 or by email at PPNO@health.ny.gov.
  • MMC general coverage questions should be directed to the OHIP, Division of Health Plan Contracting and Oversight by email at covques@health.ny.gov or by telephone at (518) 473-1134.
  • MMC reimbursement, billing, and/or documentation requirement questions should be directed to enrollee MMC Plans. MMC Plan contact information can be found in the eMedNY New York State Medicaid Program Information for All Providers Managed Care Information document.