On August 16, 2022, President Biden signed the Inflation Reduction Act (IRA), which includes several provisions that will significantly impact the healthcare system in the United States. Specific to vaccines, Section 11405 of the IRA establishes federal coverage requirements across all Medicaid programs and populations, resembling existing coverage standards for the commercial insurance market. The new requirements create a pathway for all Medicaid-enrolled adults to access recommended vaccines by requiring states to provide coverage without cost sharing by October 1, 2023. Implementation of this provision will help address gaps in vaccine coverage under Medicaid.

State Medicaid programs that currently impose cost sharing or do not cover all Advisory Committee on Immunization Practices (ACIP)-recommended vaccines will be required to make changes to comply with this provision. The process for implementing coverage changes varies by state and could involve legislation, regulation, or administrative action.

Avalere assessed Medicaid adult vaccine coverage in all 50 states plus Washington, DC, to understand coverage for ACIP-recommended vaccines prior to IRA implementation. Avalere reviewed publicly available resources and identified state coverage policies for five ACIP-recommended adult vaccines: (1) influenza; (2) tetanus, diphtheria, and acellular pertussis (Tdap); (3) human papillomavirus (HPV); (4) pneumococcal polysaccharide vaccine (PPSV23); and (5) pneumococcal conjugate vaccine (PCV13). Avalere’s analysis found 19 state policies that clearly do not cover at least one of these vaccine products or impose cost sharing for the recommended populations.

Avalere’s findings can inform stakeholder and policymaker engagement in states that are not currently compliant with the IRA coverage standards as these states take steps to implement the new requirements next year. As policymakers consider what changes are required in their states, stakeholders may also help them to identify and address remaining barriers to vaccine access not addressed in the IRA, such as provider reimbursement, pharmacy access, vaccine hesitancy, and immunization data collection.

Download the related white paper, “Adult Vaccine Coverage in Medicaid: Assessing Existing Gaps and Looking Ahead to Implementation of the Inflation Reduction Act.”

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

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