Vaccine Purchase Act
On March 20, 2015, the Vaccine Purchasing Act (VPA) went into effect, NMSA 1978, § 24-5A-1 et seq. Pursuant to the VPA, the vaccine purchasing fund was created in the state treasury. The fund consists of amounts reimbursed to the state by health insurers and group health plans for the purchase, storage and distribution of vaccines for their insured children. The Department’s rules associated with the VPA went into effect on August 28, 2015. NMAC 7.5.4.
Since the inception of the federal Vaccines for Children (VFC) program in the 1990s, the Department has purchased vaccines universally for children in New Mexico - both privately insured and VFC eligible children. The public health objective is to have a seamless vaccine distribution system in order for providers and patients to easily access childhood vaccines.
During the 2015 legislative session, the Legislature passed the VPA, requiring all insurers and group health plans doing business in the state to pay their proportionate share for childhood vaccines. The payment amount is based on a formula found in NMSA 1978, § 24-5A-6 B.
- NMAC 7.5.4 - Vaccine Purchasing Fund
Frequently Asked Questions
Why are we receiving invoices for immunizations, don’t the Doctor’s offices just bill the insurance company for immunizations?
Yes, Doctor’s offices routinely bill for the administration (giving the shot) of vaccines in their offices or clinics; however, not the cost of the vaccine itself, the State of New Mexico has been providing the vaccine to providers through the universal purchase policies.
Under whose authority are you invoicing insurance carriers?
The 2015 New Mexico Legislature, enabled the Immunization Program to bill insurance carriers for the cost of vaccine; pursuant to Sections 24-5a-1 through 24-5a-9 of the Vaccine Purchasing Act, NMSA 1978; Section 9-7-6 of the Department of Health Act, NMSA 1978; and Section 24-1-3 of the Public Health Act, NMSA 1978.
I think this is a mistake, our company does not market health insurance coverage, is there an exemption process?
If you are an Insurance Provider that does not provide health coverage, simply let us know at firstname.lastname@example.org so that we can remove you from the list; we will need to know the name of your company, a contact person and what kind of coverage you provide. If you should at some point in the future, add health insurance to your list of services, you will have to comply at that point.
We are not an insurance carrier, I think the invoice was sent in error?
If you are a self-funded carrier (employer), then the statute applies to you; the law stipulates that the DOH is to “invoice each health insurer and group health plan to reimburse the department for the cost of vaccines provided to privately insured children (dependents).” Defining group health plan as “an employee welfare benefit plan to the extent that the plan provides medical care to employees or their dependents.”
What if a company is located outside of New Mexico, are they still required to report?
Any insurance company that covers children in the State of New Mexico, must reimburse the State for their portion of the cost of the vaccine.
How do we know what our portion is?
The insurance companies portion is based on a the total cost for vaccine the Immunization Program estimates will be expended in the coming fiscal year (July 1 through June 30) plus a 10% reserve; divided by the number of insured lives in the State of New Mexico. This years’ estimate (FY16) is $20,226,256.34.
Will this number change?
Per statute the Immunization Program can adjust the invoice on a quarterly basis if the cost of vaccine is varying from the estimated cost.
How did you get the number of lives on the invoice?
Insurer(s) were asked to report the number of lives as of December 31, 2014 (the previous calendar year); these numbers were collected by the Office of Superintendent of Insurance through an on-line tool (Survey Monkey).
How is that possible, no one in our office responded to any survey?
In the case of some self-funded employers, their Third-Party Administrator (TPA) responded without letting their clients know of the notice or the response. You may want to check with your TPA to see if they responded for you; and verify the accuracy of what they reported.
What if the number of lives reported is not correct?
Annual reporting for number of covered lives under age 19 as of Dec. 31, 2015 will take place in June 2016. Please plan to submit your corrected number at that time to email@example.com, following instructions from the Office of Superintendent of Insurance.
For any changes that will affect the current fiscal year (4th quarter only), we are asking that formal documentation be provided to the Immunization Program for the following requests:
- Revised number of covered lives, either increased, decreased, or no covered lives for the reporting period.
What if my company is not a self-funded carrier?
Notify the Immunization Program (firstname.lastname@example.org) that your company is fully funded, provide the name of the carrier, and you will be taken out of the invoicing database. However, should you ever insure children in the future, you will have to notify the Department of Health. Please email email@example.com to invoice you accordingly.
How often will I receive a bill?
By statute, the Immunization Program will bill for reimbursement on a quarterly basis; the 1st of every September, December, March and June.
What if my payment is late; will I be subject to a penalty?
Section 24-5A-7(D) NMSA 1978 indicates that the State of New Mexico shall assess a civil penalty of $500 for each day an invoice remains unpaid; however, because the program is in the process of determining the validity of a few outstanding invoices, no penalty will be assessed until after September, 2016. This will allow one full year of collections and adjustments to take effect as a result of the newly implemented programming.
Will we have to report our “covered lives” every quarter as well?
No, the number of “covered lives” is reported once per year, by July 1st, based on data from the previous calendar year (December 31st.)
Who is responsible to report, the Self-Funded Entity or their Insurance Carrier?
That is something that needs to be negotiated between the employer and their third party administrator.
How will reporting be made transparent?
The Immunization Program shall provide a list of the Providers to whom they issue vaccine and a copy of the estimated cost of vaccine for the upcoming year.
What if I don’t agree with the amount on my invoice?
If after all the information has been provided, and you are still not satisfied with the amount owed, you can request an administrative review. “The health insurer or group health plan may submit a letter requesting an initial administrative review of the invoice and any supporting documents to the immunization program manager or designee within 10 working days of receipt of the department’s invoice. Such requests shall be submitted to the Immunization Program Manager at P.O. Box 26110, Santa Fe, NM 87502-6110, and via email at firstname.lastname@example.org. The health insurer or group health plan shall send a copy of the request to the office of the superintendent of insurance.”
What if I am still not satisfied with the amount owed?
Only after the administrative review is completed; “A health insurer aggrieved pursuant to the Vaccine Purchasing Act may request an informal hearing or an administrative review with the office of the superintendent pursuant to their rules. The health insurer shall notify the immunization program manager if they are pursuing an informal hearing or administrative review with the office of the superintendent via email at email@example.com.”