State Policies on Access to Vaccination Services for Low-Income Adults

Abstract

Importance: State vaccination benefits coverage and access for adult Medicaid beneficiaries vary substantially. Multiple studies have documented lower vaccination uptake in publicly insured adults compared with privately insured adults.

Objective: To evaluate adult Medicaid beneficiaries' access to adult immunization services through review of vaccination benefits coverage in Medicaid programs across the 50 states and the District of Columbia.

Design, setting, and participants: A public domain document review with supplemental semistructured telephone survey was conducted between June 1, 2018, and June 14, 2019, to evaluate vaccination services benefits in fee-for-service and managed care organization arrangements for adult Medicaid beneficiaries in the 50 states and the District of Columbia (total, 51 Medicaid programs).

Exposures: Document review of benefits coverage for adult immunization services and supplemental survey with validation of document review findings.

Main outcomes and measures: Benefits coverage for adult Medicaid beneficiaries and reimbursement amounts for vaccine purchase and administration.

Results: Public domain document review was completed for all 51 jurisdictions. Among these, 44 Medicaid programs (86%) validated document review findings and completed the survey. Only 22 Medicaid programs (43%) covered all 13 Advisory Committee on Immunization Practices-recommended adult immunizations under both fee-for-service and managed care organization arrangements. Most fee-for-service arrangements (37 of 49) reimbursed health care professionals using any of the 4 approved vaccine administration codes; however, 8 of 49 programs did not separately reimburse for vaccine administration to adult Medicaid beneficiaries. Depending on administration route, median reimbursement for adult vaccine administration ranged from $9.81 to $13.98 per dose. Median per-dose reimbursement for adult vaccine purchase was highest for 9-valent human papillomavirus vaccine ($204.87) and lowest for Haemophilus influenzae type b vaccine ($18.09). Median reimbursement was below the private sector price for 7 of the 13 included vaccines.

Conclusions and relevance: Even in programs with complete vaccination benefits coverage, reimbursement amounts to health care professionals for vaccine purchase and administration may not fully cover vaccination provision costs. Reimbursement amounts below costs may reduce incentives for health care professionals to vaccinate low-income adults and thereby limit Medicaid adult beneficiary access to vaccination.

Figure 1.. Medicaid Program Coverage of All Advisory Committee on Immunization Practices (ACIP)–Recommended Adult Vaccines by Fee-for-Service (FFS) and Managed Care Organization (MCO) Arrangement

Data are from public domain document review and survey. For ACIP-recommended adult immunizations with multiple Current Procedural Terminology (CPT) codes available, benefits coverage was assumed if any 1 of the associated CPT codes was reported as covered. If a Medicaid program covered at least 1 of 3 selected influenza vaccines (inactivated, live attenuated, or recombinant), the program was considered to cover influenza vaccines. 9vHPV indicates 9-valent human papillomavirus vaccine; HepA, hepatitis A vaccine; HepB, hepatitis B vaccine; Hib, Haemophilus influenzae type b vaccine; MenACWY, serogroup A, C, W, and Y meningococcal vaccine; MenB, serogroup B meningococcal vaccine; MMR, measles, mumps, and rubella vaccine; PCV13, pneumococcal conjugate vaccine; PPSV23, pneumococcal polysaccharide vaccine; and Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine.

Figure 2.. Median and Range of Reimbursement for Advisory Committee on Immunization Practices (ACIP)–Recommended Adult Vaccine Purchase Under Fee-for-Service Arrangements, by Current Procedural Terminology (CPT) Code

Data are from public domain document review. As there are multiple vaccines available for Hep B, MenACWY, MenB, and Hib, medians were calculated only for the most frequently available CPT code for each immunization. For each box plot, the middle line designates the median reimbursement amount to health care professionals for vaccine purchase of each of the selected ACIP-recommended adult vaccinations, boxes indicate the interquartile range, and whiskers are drawn to 1.5 × interquartile range. Outliers are represented using circles. 9vHPV indicates 9-valent human papillomavirus vaccine; HepA, hepatitis A vaccine; HepB, hepatitis B vaccine; Hib, Haemophilus influenzae type b vaccine; MenACWY, serogroup A, C, W, and Y meningococcal vaccine; MenB, serogroup B meningococcal vaccine; MMR, measles, mumps, and rubella vaccine; PCV13, pneumococcal conjugate vaccine; PPSV23, pneumococcal polysaccharide vaccine; and Tdap, tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine. Vaccine CPT codes are as follows: influenza, inactivated (IIV), 90656; influenza, live attenuated (LAIV), 90682; influenza, recombinant (RIV), 90672; Tdap, 90715; PCV13, 90670; PPSV23, 90732; HepA, 90632; HepB, 90746; MenB, 90620; MenACWY, 90734; 9vHPV, 90651; MMR, 90707; varicella, 90716; zoster, 90750; and Hib, 90648.