CMS Affirms States Must Cover Stand-Alone Vaccine Counseling under EPSDT, More Work to Be Done

As families and parents across the country eagerly await approval of the COVID-19 vaccine for children under 5, new guidance from CMS reaffirms that states must cover stand-alone vaccine counseling for children covered by Medicaid under EPSDT.

According to guidance released last week, CMS reiterates that under Medicaid’s Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit, states are required to provide coverage of stand-alone vaccine counseling for children enrolled in Medicaid and Medicaid-expansion CHIP coverage who are eligible for EPSDT, reaffirming earlier Administration statements. This means that states must cover counseling to a parent and/or caregiver for a vaccine for a child eligible for EPSDT even if the patient does not end up getting the vaccine.

Importantly, CMS emphasizes that this requirement applies to stand-alone vaccine counseling related to all vaccines covered for children under EPSDT such as regular immunizations. When it comes to the COVID-19 vaccines, CMS clarifies that state expenditures for such costs are federally matched at 100 percent for children covered by Medicaid and Medicaid-expansion CHIP plans who are eligible for both EPSDT and the American Rescue Plan’s COVID-19 coverage requirements during the APR FMAP period (which runs through the public health emergency period until about a year after).

The guidance comes at an important time as vaccination rates begin to stagnate and even drop in some cases. According to CDC summary data from the American Academy of Pediatrics, about 18.5 million children ages 5-11 and 7.9 million children ages 12-17 have yet to receive their first COVID-19 dose. In addition, as highlighted by CMS in its guidance, when it comes to childhood vaccines more generally, there has been a decline in the number of all childhood vaccines provided to Medicaid and CHIP populations during the public health emergency (with only the exception of the flu vaccine). The CDC has also noted declines in childhood vaccination rates with a recent study finding a drop in overall vaccination coverage for kindergartners nationwide when comparing the 2020-21 to 2019-20 school years. Such findings call to attention the need for more counseling and opportunities for parents to receive information about vaccines from trusted health providers such as through vaccine counseling.

However, in order for coverage of stand-alone vaccine counseling to actually help children eligible for EPSDT, providers and families must know about it. For this reason, additional education and awareness for states, plans, providers, and families about Medicaid’s mandated coverage for stand-alone vaccine counseling for children eligible for EPSDT may be especially important. It is also an area where stakeholders can help spread the word.

CMS’s recent guidance affirming these protections is an important tool in the toolbox for children who are currently covered by Medicaid and eligible for EPSDT. Yet, an estimated 7 million children nationwide are at considerable risk of losing coverage when the public health emergency continuous eligibility protection ends. This is on top of the many children including families making less than 200 percent of the federal poverty level who remain uninsured. What happens to them?

The HRSA COVID-19 Uninsured Program, established and funded by Congress, had been helping to reimburse health care providers who provided COVID-19 testing, treatment, and vaccine administration services (although not stand-alone vaccine counseling) to uninsured individuals. However, due to lack of sufficient funds, the Uninsured Program has since stopped accepting claims. Without additional Congressional funding, uninsured children and families face the loss of access to COVID testing, treatment, and vaccine administration services.

This week, a number of groups including the American Academy of Pediatrics, Children’s Hospital Association, and Children’s Defense Fund called on Congress to restore support for the Uninsured Program to help ensure everyone, regardless of insurance status, can continue to access lifesaving vaccines, testing, and treatment. Next steps remain unclear but we will be watching closely.

Anne Dwyer is an Associate Research Professor at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.