COVID-19 Vaccine and Reimbursement Guidelines for 2024-2025 for NC Medicaid

The following information is applicable to NC Medicaid Direct and NC Medicaid Managed Care.

On June 27, 2024, the Centers for Disease Control (CDC) Advisory Committee on Immunization Practices (ACIP) recommended 2024–2025 COVID-19 vaccination with an FDA-approved or authorized vaccine for ages 6 months and older. On Aug. 22, 2024, the Food and Drug Administration (FDA), approved new COVID-19 vaccines for the 2024-2025 season, FDA: Covid-19 Vaccines. For details on the 2024-2025 Covid-19 vaccines, visit the CDC's MMWR: Use of COVID-19 Vaccines for Persons Aged ≥6 Months: Recommendations of the Advisory Committee on Immunization Practices — United States, 2024–2025.  

NC Medicaid will cover the COVID-19 2024-2025 vaccines and CPT codes 91318-91322 with an effective date of Aug. 22, 2024.

The Novavax vaccines for the 2024-25 season under CPT code 91304 are covered with an effective date of Aug. 30, 2024.  

COVID-19 vaccines are part of the Vaccines for Children program (VFC) (CDC VFC List) for beneficiaries ages 18 and younger. Based on updated Centers for Medicare and Medicaid (CMS) guidance related to the PREP Act, NC Medicaid will cover pharmacy point-of-sale claims for COVID-19 vaccines for beneficiaries ages 3 and older through Dec. 31, 2024. Beginning Jan. 1, 2025, NC Medicaid will only cover COVID-19 vaccines for beneficiaries ages 19 and older in the pharmacy point-of-sale setting. 

COVID-19 Vaccine Reimbursement

NC Medicaid will reimburse at the Medicare-approved COVID-19 vaccination administration rate of $65 until Sept. 30, 2024. Please refer to Reminder: Key COVID-19 Changes Effective Oct. 1, 2024 and any related updates for coverage after Oct. 1, 2024.  

For Medicaid Billing:

• The ICD-10-CM diagnosis code(s) required for billing is/are: Z23 - Encounter for immunization.
• Providers must bill with the correct HCPCS codes for the COVID-19 vaccine administered.
• Providers shall bill their usual and customary charge for non-340B drugs.
• The Physician Administered Drug Program (PADP) reimburses for drugs billed for Medicaid beneficiaries by 340B participating providers who have registered with the Office of Pharmacy Affairs (OPA). Providers billing for 340B drugs shall bill the cost that is their actual acquisition cost. Providers shall indicate that a drug was purchased under a 340B purchasing agreement by appending the “UD” modifier on the drug detail.
• The fee schedule for the PADP is available on the NC Medicaid Fee Schedule & Covered Code portal.
• The maximum reimbursement rate per unit is Wholesale Acquisition Cost (WAC) +3% and is National Drug Code (NDC) specific.
• As of Oct. 1, 2024, NC Medicaid ended coverage for CPT 99401 for COVID-19 vaccine counseling and added coverage of “stand-alone” vaccine counseling codes G0310, G0312 and G0315. Providers should use codes G0310, G0312, and G0315 for vaccine counseling when the vaccine is not administered on the same date of service. Please refer to Reminder: Key COVID-19 Changes Effective Oct. 1, 2024 and any related updates for coverage after Oct. 1, 2024.
• Claims must have appropriate NDCs that correspond to the vaccine used for administration and corresponding CPT code.
• Claims must contain both administration codes and vaccine codes to pay.
• Copays cannot be charged for COVID-19 immunization or administrations.
• COVID-19 vaccines are now part of the VFC program for beneficiaries ages 18 years and younger.  
• An EP modifier should be appended to all vaccine administration codes for NC Medicaid beneficiaries under age 21.
• CG modifier should be appended to ALL COVID-19 vaccine AND administration claims submitted by a pharmacy participating in the immunization program. 

COVID-19 Vaccine Counseling Coverage

For coverage until Sept. 30, 2024, refer to SPECIAL BULLETIN COVID-19 #268: COVID-19 Testing, Vaccination and Counseling Coverage After the Federal Public Health Emergency.

For coverage after Oct. 1, 2024, refer to Reminder: Key COVID-19 Changes Effective Oct. 1, 2024 and any related updates.

NC Immunization Program/Vaccines for Children  

Under NC Immunization Program/Vaccines for Children (NCIP/VFC) guidelines, the NC Division of Public Health (DPH) Immunization Branch distributes all childhood vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) to local health departments, Federally Qualified Health Centers (FQHC), Rural Health Clinics (RHC), hospitals and private providers.

For the 2024-2025 COVID-19 season, NCIP/VFC COVID-19 vaccines are available at no charge to providers for children ages 6 months through 18 who are eligible for the VFC program. The current NCIP coverage criteria and definitions of VFC categories can be found on DPH’s Immunization Branch webpage. 

For providers interested in enrolling in the VFC program, information can be found on the CDC information page and the NC DPH website.  

Eligible VFC children include ALL Medicaid beneficiaries through age18.

For VFC/NCIP vaccines administered to VFC-eligible children, providers must report only the vaccine code(s) with $0.00. Providers may bill NC Medicaid for the administration fee for Medicaid.

Providers who administer privately purchased vaccines to VFC eligible beneficiaries will NOT be reimbursed for the vaccine and cannot bill the beneficiary for the cost. Only the administration fee(s) will be reimbursed.  

An exception is made for COVID-19 vaccines. If a VFC eligible beneficiary received a non-VFC provided COVID-19 dose from a pharmacy provider authorized to administer the vaccine under the HHS COVID-19 PREP Act declaration, NC Medicaid will reimburse the vaccine through Dec. 31, 2024.  

Providers must purchase vaccines for beneficiaries who are not VFC-eligible. For Medicaid-eligible beneficiaries ages 19 and older, purchased vaccine and administration costs may be billed to NC Medicaid, according to the guidelines stated in Tables 2 and 3 below. To determine who is eligible for NCIP COVID-19 and other vaccines, visit DPH’s Immunization Branch webpage.  

Billing/Reporting COVID-19 Vaccines for Medicaid Beneficiaries

The following tables indicate the vaccine codes that may be either reported (with $0.00 billed) or billed (with the usual and customary charge) for the COVID-19 vaccine, depending on the age of the beneficiary and the formulation of the vaccine. The tables also indicate the administration codes that may be billed, depending on the age of the beneficiary and the vaccine(s) administered to them.

Note: Specific information on billing all immunization administration codes for Health Check beneficiaries can be found in the Health Check Program Guide available at NCTracks Provider Policies, Manuals, Guidelines, and Forms.

If you have any questions or need assistance, contact the Immunization Branch Help Desk at 877-873-6247 and press option 6. 

Table 1 
COVID-19 Billing Codes for Medicaid Beneficiaries ages 18 or younger Who Receive VFC COVID-19 Vaccine. These codes are reported with $0.00. 

*NDCs listed on Table 1 are NDCs of packs of vials as distributed by DPH. For claims processing, providers should use the NDC listed on the actual vial used for administration as listed at the bottom of this bulletin.

Please refer to Reminder: Key COVID-19 Changes Effective Oct. 1, 2024 for administration code information and any related updates for coverage after Oct. 1, 2024. 

Table 2 
COVID-19 Billing Codes for Medicaid Beneficiaries ages 19 to 21 

Use the following codes to bill Medicaid for a COVID-19 vaccine purchased and administered to beneficiaries ages 19 to 21.

Note: The VFC/NCIP provides COVID-19 products for recipients ages 6 months through 18 only. The VFC/NCIP will NOT provide COVID-19 vaccine for recipients 19 years and older.  

Administrative CPT Codes to Report 
Please refer to Reminder: Key COVID-19 Changes Effective Oct. 1, 2024 for administration code information and any related updates for coverage after Oct. 1, 2024. 

Table 3 
COVID-19 Billing Codes for Medicaid Beneficiaries ages 21 and older

Use the following codes to bill Medicaid for COVID-19 vaccine purchased and administered to beneficiaries ages 21 and older.

Note: The VFC/NCIP provided COVID-19 products for VFC-age (ages 6 months through 18) beneficiaries only. The VFC/NCIP will not provide COVID-19 vaccine for beneficiaries ages19 and older. 

Administrative CPT Code(s) to Bill 
Please refer to Reminder: Key COVID-19 Changes Effective Oct. 1, 2024 for administration code information and any related updates for coverage after Oct. 1, 2024. 

Immunization Billing for Medicaid from FQHCs and RHCs 

For beneficiaries ages 0 through 20  

• If vaccines are provided through the NCIP/VFC, the center/clinic shall report the CPT vaccine codes (with $0.00 billed) under Physician Services NPI and may bill for the appropriate administration codes (e.g. see Reminder: Key COVID-19 Changes Effective Oct. 1, 2024). This billing is appropriate when only vaccines are provided at the visit, or if vaccines were provided in conjunction with a wellness check. If a core visit was billed, CPT vaccine codes shall be reported (with $0.00 billed) under Physician Services NPI and an administration code shall not be billed.
• If purchased vaccines (non-VFC eligible) were administered, the center/clinic may bill the CPT vaccine codes (with their usual and customary charge) under the Physician Services NPI for the vaccines administered and may bill for the administration codes (with the usual and customary charge). This billing is appropriate if only vaccines were given at the visit or if vaccines were given in conjunction with a wellness check. If a core visit was billed, CPT vaccine codes shall be reported (with $0.00 billed) under the Physician Services NPI provider number and the administration codes shall not be billed. For detailed billing guidance, refer to the Health Check Program Guide available at NCTracks Provider Policies, Manuals, Guidelines, and Forms.

For beneficiaries ages 21 and older

• When purchased vaccines are administered, CPT vaccine codes may be billed (with the usual and customary charge) and administration codes may be billed (with the usual and customary charge) under the Physician Services NPI. This is applicable when vaccine administration was the only service provided that visit. When a core visit is billed, the CPT vaccine code shall be reported (with $0.00 billed) under the Physician Services NPI and an immunization administration code may not be billed.
• For COVID-19 vaccine and administration fee rates, refer to the DHB's Physician Administered Drug Program (PADP) and Physician Services Fee Schedule. 

Immunization Billing for Medicaid Beneficiaries from Immunizing Pharmacies 

For beneficiaries ages 19 and older

Effective Jan. 1, 2016, NC Medicaid will reimburse pharmacies for covered vaccines, including COVID-19 vaccines, as permitted by G.S. 90-85.15B (see below) when administered to NC Medicaid beneficiaries ages 19 and older by an immunizing pharmacist.

Pharmacies will be allowed to bill NC Medicaid Direct for vaccines on pharmacy claims at point of sale. Immunizing pharmacists are not required to submit vaccine administration claims on medical 837P or CMS 1500 form, but this will remain an option for immunizing pharmacists who wish to do so. Additional information can be found in the Vaccine Immunization Claims Can Be Submitted on Pharmacy Claims for NC Medicaid Direct Beneficiaries published Nov. 28, 2022.

Based on updated CMS guidance related to the PREP Act, NC Medicaid will begin covering pharmacy point of sale claims for COVID-19 vaccines for beneficiaries ages 3 and above through Dec. 31, 2024.

The Vaccine Point-of-Sale (POS) Catalogs and Rate Listings is maintained with vaccine POS and rate listing information.   

For NC Medicaid Managed Care health plans, pharmacy providers should refer to communications from the beneficiary’s plan for vaccine claim submission guidance.  

Table 4 
Billing Codes to be used by Pharmacist for Medicaid Beneficiaries ages 19 and older via CMS 1500 or 837P Claims 

*The CG modifier must be appended to every vaccine and vaccine administration CPT code used to bill vaccines by pharmacists. The CG modifier identifies a Pharmacy Provider in NCTracks for vaccine claims billing purposes.  

**Coverage in pharmacy for beneficiaries ages 18 and younger will end Dec. 31, 2024. Effective Jan. 1, 2025, pharmacies will no longer be able to administer COVID-19 vaccines to beneficiaries ages 18 and younger. 

Billing Codes to be used by Pharmacists for NC Medicaid Beneficiaries ages 19 and above via CMS 1500 or 837P Claims 

Please refer to Reminder: Key COVID-19 Changes Effective Oct. 1, 2024 for administration code information and any related updates for coverage after Oct. 1, 2024.

For NC Medicaid Direct, the CG modifier must be appended to every vaccine and vaccine administration CPT code used to bill vaccines by pharmacists. The CG modifier is used to identify pharmacy providers in the system for vaccine billing purposes.

For NC Medicaid Managed Care health plans, pharmacy providers should refer to the beneficiary’s specific plan for detailed guidance on COVID-19 vaccine claim submissions. This ensures compliance with any plan-specific billing procedures or requirements.

Please note that NDCs are required on vaccine claims. 

NDC’s Change Each Year for COVID-19 Vaccines 

Providers are required to use appropriate NDCs that correspond to the vaccine used for administration and corresponding CPT code. Note not all products and NDCs under their respective CPT codes will be covered.  

COVID-19 vaccines are licensed each year with new NDCs, so it is important to report the correct code for the products you are using to avoid having claims deny with edit 00996 (Mismatched NDC) which will require the claim to be resubmitted with the correct NDC. Below are the COVID-19 vaccine procedure (CPT) codes and corresponding NDCs that should be used for the 2024-2025 COVID-19 season: 

CPT and NDC codes for the 2024-2025 COVID-19 Vaccine Products for Pharmacies* 

*Note for PADP medical claims, the PADP fee schedule is updated monthly with current CPT-NDC combinations and the Vaccine Point-of-Sale (POS) Catalogs and Rate Listings webpage is updated regularly with current NDCs for pharmacy point-of-sale claims.  

**Coverage in pharmacy for beneficiaries ages 18 and younger will end Dec. 31, 2024. Effective Jan. 1, 2025, pharmacies will not be able to administer COVID-19 vaccines to beneficiaries ages 18 and younger. 

Contact

NCTracks: 800-688-6696 

Health Plan Pharmacy Lines

Standard Plans

• AmeriHealth: 1-866-885-1406
• Healthy Blue: 1-833-434-1212
• Carolina Complete:  1-833-992-2785
• United Healthcare:  1-855-258-1593
• WellCare: 1-866-799-5318, option 3

Tailored Plans

• Alliance Health: 1-855-759-9300
• Partners: 1-866-453-7196
• Trillium: 1-866-245-4954
• Vaya Health: 1-800-540-6083