Ensuring equitable vaccine access for Medicaid beneficiaries is a priority for policymakers, particularly given disparities in vaccination rates between commercially insured members and Medicaid beneficiaries. Medicaid covers vulnerable populations such as low-income adults and individuals who are pregnant. In 2022, Avalere published findings from an analysis that highlighted the impacts of the Inflation Reduction Act (IRA) on vaccine coverage requirements across Medicaid programs. Although the IRA addresses vaccine coverage gaps in Medicaid, no federal regulations govern Medicaid reimbursement to healthcare providers for adult vaccines. Provider reimbursement rates for vaccine products and administration vary, and lower rates may influence provider decisions to stock vaccines, affecting patient access.

Reimbursement policies also vary by provider type. For example, pharmacies in some states are ineligible to receive reimbursement under Medicaid for vaccine administration, which limits immunization settings available to beneficiaries. Similarly, Medicaid payment rules for Federally Qualified Health Centers (FQHCs) differ from those for other providers in ways that could disincentivize vaccination, including by not directly reimbursing for vaccines and limiting the types of providers within an FQHC that can be reimbursed for vaccine administration.

Findings

To characterize this landscape, Avalere assessed state Fee-for-Service Medicaid reimbursement policies for physician offices, pharmacies, and FQHCs in all 50 states and DC. Avalere reviewed publicly available sources from 2021 to identify reimbursement policies for four recommended adult vaccines: (1) tetanus, diphtheria, and acellular pertussis; (2) pneumococcal polysaccharide vaccine; (3) human papillomavirus; and (4) pneumococcal conjugate vaccine. Findings showed variability in physician office vaccine administration and product reimbursement rates:

• Eighty-two percent¹ of states plus DC reimbursed vaccine administration below the 2021 Medicare Physician Fee Schedule National Payment Amount ($17.10).²
• At least six states and DC reimbursed physician offices below the private sector price for all four reviewed vaccines.
• Ten states did not allow pharmacies to obtain reimbursement for any of the reviewed vaccines.
• Twenty-five states did not allow pharmacies to obtain reimbursement for at least one of the reviewed vaccines.
• Most states did not reimburse FQHCs for vaccine products and administration outside the encounter payment (i.e., few states reimburse separately for vaccines).

Reimbursement under Medicaid remains a barrier to providers stocking and administering vaccines. Avalere’s findings demonstrate the variability in Medicaid vaccine reimbursement across states and could help inform stakeholder and policymaker engagement to improve Medicaid vaccine access in the future.

Download the related white paper,”50-State Comparison of Medicaid Adult Vaccine Provider Reimbursement.”

Funding for this research was provided by Pfizer. Avalere Health retained full editorial control.

To learn more about the IRA’s impact on vaccine coverage, connect with us.

Notes

1. Includes three states for which information was not available.
2. The Medicare Physician Fee Schedule values 90471 separately from the Part B preventive vaccine administration fee (G009).