Continued Challenges With Medicaid Coverage of Adult Vaccines and Vaccination Services

Key Points Question What level of access to vaccination services do Medicaid programs provide to adult beneficiaries enrolled in fee-for-service and managed care organization arrangements? Findings In this survey study of Medicaid programs, 22 of 51 programs covered all 13 adult vaccines recommended by the Advisory Committee on Immunization Practices for both fee-for-service and managed care organization enrollees. Reimbursement for vaccine administration was disparate; median vaccine purchase reimbursement was highly variable relative to manufacturer-reported private sector price. Meaning These findings suggest that most adult Medicaid beneficiaries do not have access to all 13 Advisory Committee on Immunization Practices–recommended adult vaccines; low reimbursement for vaccine administration and purchase may disincentivize health care professionals to vaccinate low-income adults.
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.
This survey study evaluates 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.