Bailey Spates is a Program Specialist with NACHC’s Regulatory Affairs department.
Vaccines are one of our greatest tools to combat serious illnesses, hospitalizations, and even death. The CDC estimates that Americans born between 1994 and 2013 will avoid a staggering 322 million illnesses, 21 million hospitalizations, and 732,000 deaths thanks to vaccines over their lifetimes. That’s a public health victory worth celebrating! But the reality is, not everyone has equal access to this lifesaving protection. That’s where Community Health Centers step in as champions for health equity. Health centers understand that underserved communities often face barriers to healthcare, including access to vaccinations, and therefore strive to provide their patients with vital immunizations.
In February, CMS released a helpful new toolkit outlining State flexibilities to empower providers like Community Health Centers to better understand vaccine coverage and cost-sharing for Medicaid and Children’s Health Insurance Program (CHIP) beneficiaries, ultimately helping move towards more equitable vaccine access and coverage.
For a quick summary, review this NACHC infographic. The following analysis looks at the impact of recent policy changes within the new toolkit and its potential to improve vaccine access for health center patients.
A Focus on Flexibilities Helping Community Health Centers
The CDC, along with the Advisory Committee on Immunization Practices (ACIP)— a committee of experts that work to provide recommendations for best vaccine administrations for preventable diseases—has a list of approved vaccines that are now covered for Medicaid and CHIP beneficiaries, thanks to the Inflation Reduction Act. The expanded list, which includes the COVID-19 vaccine, ensures continued equitable access to critical vaccines for both children and adults. To understand the importance of this further, let’s explore the current landscape of vaccine coverage in children.
States must cover Medicaid and CHIP beneficiaries under age 21 eligible for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit. This means beneficiaries have coverage for all immunizations recommended by the CDC and ACIP pediatric immunization schedule. For CHIP programs that choose to offer EPSDT coverage, the same rules apply; they must also follow EPSDT requirements for immunizations. Additionally, children under age 18 (or 21 at some states’ discretion) are exempt from Medicaid cost-sharing, including for vaccinations.
For our youngest patients who are enrolled in Medicaid (up to age 18) or are uninsured, underinsured, or American Indian/Alaska Native, there’s no change! The Vaccines for Children (VFC) program, established in 1994, plays a critical role in ensuring equitable access to essential childhood immunizations. By promoting widespread vaccination coverage, the VFC program contributes significantly to the overall health and well-being of families and communities.
Expanding Adult Immunizations: The Impact of the Inflation Reduction Act
Thanks to the Inflation Reduction Act, as of October 1st, 2023, adults 19 and over with traditional Medicaid and certain medically needy benefits have coverage on ALL the recommended adult vaccines covered by Medicaid, with no out-of-pocket costs. This includes both the vaccine itself and the administration fee. Unfortunately, if beneficiaries are on an alternative Medicaid benefit plan, the IRA coverage doesn’t apply. However, coverage will still apply for the standard, routine vaccinations recommended by ACIP, also with no cost-sharing.
As healthcare homes for their patients, Community Health Centers can help provide access to these vaccines for their communities, helping patients achieve better health outcomes. Health centers see 1 in 5 Medicaid patients, and these changes now mean over 15 million patients have access to routine and essential vaccines.
State Vaccine Reimbursement Options for Community Health Centers
Across the country, states implement a wide range of reimbursement models to cover costs associated with administering vaccines. For Medicaid and CHIP enrollees, the cost of administering a vaccine might be bundled into the existing prospective payment system (PPS) rate Health centers receive for the entire visit. Other states might use a different payment method such as the Alternative Payment Methodology, but the idea is similar: there is coverage of the vaccine and vaccine administration within the overall visit cost. States can also choose to set higher PPS rates to recognize the extra costs of giving certain vaccines.
To streamline reimbursement for vaccinations, states could implement separate payments for vaccines at approved per-dose rates, independent of the standard health center PPS rate. This approach mirrors Medicare’s established rates for vaccine administration costs, potentially simplifying the process for Health centers. Additionally, CMS recommends states review their requirements for CHC/Rural Health Clinic encounters to ensure clear guidance for providers to accurately bill for vaccines. The bottom line is that no matter how they get paid, Health centers are committed to providing vital vaccinations. If you have questions about your state’s specific reimbursement model, contact your state Medicaid agency.
Obstacles to Expanding Vaccine Accessibility through Health Centers
Despite the positive impact of the IRA, broader policy barriers continue to hinder health centers’ ability to provide essential vaccines to our patients. We recently addressed these issues in our white paper, “Strategies to Address Policy Barriers to Adult Immunizations in Federally Qualified Health Centers (2024).“ As the cornerstones of healthy communities, health centers strive to ensure everyone has access to affordable vaccines. However, persistent barriers threaten this equitable access, making advocacy a crucial tool in securing the resources we need to fulfill this vital role.
1. Earmark Resources to Address the Financial Burden of Upfront Vaccine Purchases for Health Centers: To ensure health centers can offer the full range of vaccines communities need, we must address the financial burden of upfront vaccine purchases. Allocating resources and advocating for higher reimbursement rates that reflect vaccine administration costs are crucial steps to being able to expanding vaccine access for the health center community.
2. Streamline Reimbursement with Simplified Billing Codes and Expand the Workforce: Confusing billing codes create roadblocks for CHC reimbursement of essential vaccinations. Advocating for clear definitions of CHC encounters ensures proper payment, keeping these vital programs sustainable. The HHS COVID-19 Public Readiness and Emergency Preparedness Act (PREP Act) continues to offer liability protection for pharmacies, pharmacists, pharmacy interns, and pharmacy technicians administering COVID-19 vaccines, seasonal influenza vaccines, and COVID-19 tests until December 31st, 2024. However, these flexibilities will end at the end of 2024, going back to pre-COVID times where only certain providers could bill for vaccine administration. To improve vaccine accessibility and address workforce limitations, expanding the pool of billable, authorized vaccine providers is a key advocacy message.
By understanding the new vaccine coverage options and advocating for further improvements, Community Health Centers can continue to be true champions for affordable vaccines. Regardless of their patients’ ability to pay, Health centers can provide important vaccinations for their patients to stay healthy. Remember, this is just the beginning. Stay tuned for more information on how health centers are working to keep your community healthy.
PHOTO CREDIT: Mary’s Center, Washington, DC