COVID-19 Vaccine Procedure Code 91304 is Now a Benefit of Medicaid and CHIP

Effective for dates of service on or after October 3, 2023, in accordance with the U.S. Food and Drug Administration’s (FDA) amended emergency use authorization for the Novavax COVID-19 vaccine, vaccine procedure code 91304 is now a benefit of Medicaid and CHIP.

COVID-19 vaccine procedure code 91304 is a benefit of Medicaid and CHIP for individuals who are 12 years of age or older that may be reimbursed for the following provider types and places of service:

Notes:

Texas Health Steps providers may be reimbursed for services rendered to members who are 12 years through 20 years of age in the office, home, outpatient hospital, and other location settings. Healthy Texas Women (HTW) and the Family Planning Program (FPP) providers may also be reimbursed for services rendered in family planning clinics.
Vaccine procedure code 91304 may be billed with vaccine administration procedure code 90480, as of October 3, 2023.
Vaccines administered to individuals eligible for the Vaccines for Children (VFC) program should come from VFC-provided stocks. TMHP will process COVID-19 vaccine products submitted for reimbursement as informational only when administered to individuals 6 months through 18 years of age.

As a reminder, Texas Medicaid and CHIP do not cover vaccines that are not authorized or approved by the FDA.

Additional Information:

The Texas Health and Human Services Commission (HHSC) will not cover procedure code 91304 as non-risk payments. As referenced in the notice titled “Update on Reimbursement for Non-Risk Criteria for COVID-19 and CHIP Copay Waiver” published on June 8, 2023, the NRP COVID-19 reimbursement criteria had an end date of service of August 31, 2023.

Resources:

FDA Authorizes Updated Novavax COVID-19 Vaccine Formulated to Better Protect Against Currently Circulating Variants

Next steps for Providers:

Providers should share this communication with their staff.

Community First Resources: