It’s National Immunization Awareness Month—and with it comes an important reminder for pharmacists: it’s time to prepare for vaccination season. As the fall and winter virus season begin, pharmacies see an influx of vaccination requests and need amongst their community.
And while vaccinations are a critical preventative health initiative across children and adults alike, there is great need amongst the growing elderly population to be vaccinated quickly and safely.
While retail pharmacies or combo pharmacies can support the older population, long-term care pharmacies are uniquely positioned to provide vaccination services to residents and staff at their partner facilities.
As the role of pharmacists in vaccine administration continues to evolve, so does the way in which pharmacies are reimbursed for their work. In 2021, the Centers for Medicare and Medicaid Services (CMS) announced an additional payment for administering the COVID-19 shot in the home for certain Medicare patients. In 2024, CMS updated the policy to include three more Medicare Part B preventive vaccines: Flu, Hepatitis B, and Pneumococcal. And yet, in 2024 just 58% of nursing home residents received the flu vaccine. Worse, just 30% of elderly residents received the 2024-2025 COVID-19 vaccine.
At RedSail’s Connect 2025 Conference, speakers Ed Vess and Bryce McCoy presented how long-term care pharmacies can utilize these additional reimbursements to build a cost-effective, in-home vaccination program.
We know pharmacists aren’t getting paid for their work. Reimbursement and delays of payment to pharmacies by payers (including government agencies like Medicare, Medicaid) is a constant battle, made more difficult by the pesky prescription benefit managers (PBMs).
While reimbursement for pharmacies typically comes from Medicare Part D (covering prescription drugs), the pharmacy industry is diligently pushing for “Provider Status” under Medicare Part B.
Essentially, this means pharmacists would be paid for the services they provide, like MTM, point-of-care testing, and other disease management. While the policy push continues, CMS has recently offered additional payment to pharmacies for in-home administration of preventive vaccines—and it’s time for pharmacies to take advantage.
It can be hard to keep up with policy changes and ensure you’re maximizing your profits while providing exceptional care to your patients.
So, here’s the latest:
What: In 2025, CMS will pay an additional $40 incentive fee for each in-home vaccine administration through Medicare Part B. This is an additional sum, added on top of the standard $34 payment for a vaccine. This equals ~$74 in total for one vaccine.
Who: These vaccines must be administered in private homes, assisted or independent living facilities, group homes, or non-Medicaid nursing facilities. Note: Anything that’s licensed as a nursing home, i.e. Medicare skilled nursing facilities or Medicaid nursing facilities, does not qualify.
How: Utilize the proper CPT codes for the individual vaccinations PLUS the HCPCS Level II code M0201 for the additional payment amount.
Why: If implemented properly, this is a win-win for the local patient population and the pharmacies. Not only does this increase vaccine adherence, it boosts the LTC pharmacy’s revenue and its key partners amongst the community. In addition, this program speaks to the unique value of an LTC pharmacy versus other options in the marketplace.
There are some additional specifics around where and how many patients you serve that will affect whether a pharmacy receives the additional payment.
What this looks like:
1Includes a communal space in a group living situation
2Could be an individual living unit or a communal space in a group living situation
3You can only bill for 1 in-home add-on payment in this situation because you vaccinated 10 or more Medicare patients at the same group living location on the same date
4In other words, each vaccine administered in a distinct individual living unit or communal space of a group living situation
5The example calculations reflect the payment amounts for CY 2025
Be sure to utilize this chart to schedule vaccinations at in-home settings that will maximize the payment you receive for the services provided.
The additional fee for in-home vaccinations can boost the bottom line, but it needs to be implemented effectively for maximum impact. During their session at Connect 2025, Vess and McCoy shared a few tips on how to build a successful program.
- Run frequent clinics/events. Maximize the reimbursements and the number of patients you see by setting semi-regular sessions. For example, set aside time to visit five patients at three assisted living facilities in one day near your store. If each patient receives three shots, the total reimbursement fee should come to ~$1,110 in one day. Repeat the exact same process at the exact same facilities the next month or the next week.
- Staff appropriately. Every state has different rules around who’s able to administer vaccines. Be smart about how you’re staffing these in-home events. Can you send a Pharmacy Tech and/or LPN? Do you need to send a pharmacist to supervise?
Note: Vaccine authority requirements are determined at the state level, meaning each state can specify what vaccinations are required, who can prescribe them, and who can administer them.
- Designate a subject matter expert. As described above, understanding the restrictions for the in-home additional payment can be complicated. Make sure at least one staff member becomes intimately familiar with these regulations to ensure you’re getting paid for your services.
- Adjudicate beforehand. These events can often be fast-paced, with residents lining up to be immunized. Vess and McCoy recommend billing ahead of time, even the morning of, to ensure you’re dealing with rejections beforehand and not costing the patient out-of-pocket fees.
- Build Relationships. In-home vaccination administration is a service and can help build relationships between the pharmacy and its partner facilities. This is “going the extra mile” and really showcases the value and care your pharmacy can provide for the community.
In-home vaccinations are an exciting opportunity—let’s make sure you’re ready to go! Make sure you’re prepared to bill Medicare Part B for vaccine administration.
Be sure to:
