New CMS Toolkit Outlines Vaccine Coverage and Payment Policies in Medicaid, CHIP and BHP

While it has long been clear that vaccines play a critical role in protecting individuals and communities from infectious disease, recent data show declining vaccination rates among individuals of all ages. For the 2020-21 school year, the vaccination rate among kindergartners declined nationwide, despite vaccine exemption policies remaining largely unchanged. Preliminary data indicate that among Medicaid and CHIP beneficiaries under age 19, vaccination rates declined for all vaccines except influenza from March 2020 through August 2021, compared with the same period two years prior.

CMS’ new vaccine toolkit outlines coverage and payment policies for Medicaid and CHIP and outlines strategies states can take to boost vaccine rates for children, which is the focus of this blog. There’s a lot of other information in the toolkit too, including tips on state compliance with newer rules under the Inflation Reduction Act (pertaining to adults with Medicaid), changing rules related to the COVID-19 public health emergency, and how access to the COVID-19 vaccine is changing due to the commercialization process.

Most people enrolled in Medicaid and CHIP have coverage of vaccines and vaccine administration without cost-sharing. The coverage rules vary by program, population, and whether the vaccine is considered “routine.” The Advisory Committee on Immunization Practice (ACIP) provides the Director of the Centers for Disease Control and Prevention (CDC) with guidance about which vaccines should be included on the CDC/ACIP vaccine schedules for pediatric and adult populations. Vaccines on the immunization schedules are considered routine. Other vaccines may be recommended by ACIP for certain populations – e.g., based on age group or risk group, including risk due to underlying conditions, occupation, or travel – and while such vaccines are not considered routine, they may be covered without cost-sharing too.

EPSDT requires coverage of all vaccines on the CDC/ACIP pediatric immunization schedule without cost-sharing for children in Medicaid and Medicaid-expansion CHIP. Additionally, other vaccines that are not on the pediatric immunization schedule or are not recommended by ACIP must be covered if the vaccination is determined to be medically necessary for a particular child. States must also inform families that these vaccines are available and pay for stand-alone vaccine counseling. States have the option to provide EPSDT-like vaccine coverage in separate CHIP programs, or they may limit vaccine coverage to the CDC/ACIP-recommended vaccines.

Children with Medicaid coverage (including Medicaid-expansion CHIP) and children who are uninsured, underinsured, and American Indian/Alaska Native, generally receive vaccines through the federally-funded Vaccines for Children (VFC) program. Under VFC, the CDC purchased vaccines at a discount and distributes them at no charge to private physicians’ offices and public health clinics that are registered as VFC providers. Medicaid pays an administration fee to the provider, and there are no out-of-pocket costs for the family. (Children with separate CHIP coverage are not currently eligible for VFC, though we and the American Academy of Pediatrics suggested VFC be expanded to include CHIP kids among other improvements.)

But despite this robust insurance coverage for children and access to free vaccine products for providers, vaccination rates are declining. The toolkit offers the following considerations for improving access:

  • Review licensure requirements and scope of practice laws to identify whether they can be expanded to allow additional providers to administer vaccines;
  • Streamline provider enrollment and training processes;
  • Ensure vaccine administration payment rates are set at levels that incentivize access (within the VFC maximum established for the state); and
  • Promote stand-alone vaccine counseling to ensure families have an opportunity to ask questions and learn about the importance of pediatric immunizations.

Boosting vaccination rates is key to preventing infection of serious diseases. Is there more your state can do?

Kelly Whitener is an Associate Professor of the Practice at the Georgetown University McCourt School of Public Policy’s Center for Children and Families.