Financing Vaccination of Children and Adolescents: National Vaccine Advisory Committee Recommendations

Recommendation 1

The Vaccines for Children (VFC) program should be extended to include access for VFC-eligible, underinsured children and adolescents receiving immunizations in public health department clinics and thus should not be limited to access only at federally qualified health centers and rural health clinics.

Recommendation 2

The VFC program should be expanded to cover vaccine administration reimbursement for all VFC-eligible children and adolescents. (Currently, the vaccine administration fee is not covered by the VFC program.) This should include children covered by Medicaid, because this would provide for a single system and uniform vaccine administration fee. The vaccine administration reimbursement should be sufficient to cover the costs of vaccine administration (as referenced elsewhere in these recommendations).

Recommendation 2 and recommendations 3 to 5 are designed to accomplish similar goals with respect to improving vaccine administration reimbursement in the VFC program. NVAC voted to approve both sets of recommendations with the understanding that the latter would not be needed if legislation were passed to cover administration fees for all VFC-eligible children through the VFC program, as in recommendation 2.

Recommendation 3

The Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) should annually update, publish, and disseminate actual Medicaid vaccine administration reimbursement rates according to state.

Recommendation 4

CMS should update the maximal allowable Medicaid administration reimbursement amounts for each state and should include all appropriate non–vaccine-related costs, as determined in current studies. These efforts should be coordinated with the American Medical Association review of relative value unit coding (recommendation 6).

Recommendation 5

The federal matching rate for vaccine administration reimbursement in Medicaid should be increased (ie, larger federal proportion) to levels for other services of public health importance (eg, family-planning services).

Recommendation 6

The American Medical Association Relative Value Scale Update Committee should review its relative value unit coding to ensure that it reflects accurately the nonvaccine costs of vaccination, including the potential costs and savings with the use of combination vaccines.

Recommendation 7

Vaccine manufacturers and third-party vaccine distributors should work with providers on an individual basis to reduce the financial burden for initial and ongoing vaccine inventories, particularly for new vaccines. This might include extending payment periods (eg, from 60 days to 90 or >120 days, or until vaccine has been administered and reimbursed). It also might include options not related to payment terms for vaccine inventory.

Recommendation 8

Professional medical organizations should provide their members with technical assistance regarding efficient business practices associated with providing immunizations, such as how to contract and to bill appropriately. Medical organizations should identify best business practices to ensure efficient, appropriate use of Advisory Committee on Immunization Practices (ACIP)-recommended vaccines and appropriate use of Current Procedural Terminology codes, including evaluation and management codes, in claims for vaccines and vaccine administration. These organizations may receive federal assistance from CMS or other relevant agencies.

Recommendation 9

Medical providers, particularly in smaller practices, should participate in pools of vaccine purchasers to obtain volume ordering discounts. This might be accomplished through purchasing collaboratives formed by individual providers or through regional vaccine purchasing contracts held by professional medical organizations on behalf of providers.

Recommendation 10

The CDC, professional medical organizations, and other relevant stakeholders should develop and support additional employer health education efforts. These efforts should communicate the value of good preventive care, including recommended vaccinations.

Recommendation 11

Health insurers and all private health care purchasers should adopt contract benefit language that is flexible enough to permit coverage and reimbursement for new or recently altered ACIP recommendations as well as vaccine price changes that occur in the middle of a contract period.

Recommendation 12

All public and private health insurance plans should voluntarily provide first-dollar coverage (ie, no deductibles or copayments) for all ACIP-recommended vaccines and their administration for children and adolescents.

Recommendation 13

Insurers and health care purchasers should develop reimbursement policies for vaccinations that are based on methodologically sound cost studies of efficient practices. These cost studies should factor in all costs associated with vaccine administration (including, for example, purchase of the vaccine, handling, storage, labor, patient or parent education, and record-keeping).

Recommendation 14

Congress should request an annual report on the professional judgment of the CDC regarding the size and scope of the Section 317 program appropriation needed for vaccine purchase, vaccination infrastructure, and vaccine administration. Congress should ensure that Section 317 funding is provided at levels specified in the CDC annual report to Congress.

Recommendation 15

CDC and CMS should continue to collect and to publish data on the costs and reimbursements associated with public- and private-sector vaccine administration according to NVAC standards for vaccinating children and adolescents.³ These costs include those associated with the delivery of vaccines, such as purchase of the vaccine, handling, storage, labor, patient or parent education, and record-keeping. These published data should be updated every 5 years and should include information about reimbursement according to provider type, geographic region, and insurance status. State governments should use this information in determining vaccine administration reimbursement rates for Medicaid.

Recommendation 16

The National Vaccine Program Office should calculate the marginal increase in insurance premiums if insurance plans were to provide coverage for all vaccines routinely recommended by the ACIP.

Recommendation 17

The NVAC should convene ≥1 expert panel representing all affected stakeholders, to consider whether tax credits could be a tool to reduce or to eliminate underinsurance. The panel should determine whether policy options that would be acceptable to stakeholders could be developed to address the burden of financing for private-sector child and adolescent vaccinations by using tax credits as incentives for insurers, employers, and/or employees (consumers) and whether those credits would provide added value for vaccination of children and adolescents.

Recommendation 18

The CDC should substantially decrease the time from creation to official publication of ACIP recommendations, to expedite decisions by payers related to covering new vaccines and new indications for currently available vaccines.

Recommendation 19

Congress should expand Section 317 funding to support the additional national, state, and local public health infrastructure (eg, widespread, effective education and promotion for health care providers, adolescents, and parents; coordination of complementary and alternative venues for adolescent vaccinations; record-keeping and immunization information systems; vaccine safety surveillance; and disease surveillance) needed for adolescent vaccination programs, as well as child vaccination programs for new recommendations such as universal influenza vaccination.

Recommendation 20

Federal funding for cost/benefit studies of vaccinations targeted to children and adolescents should be continued.

Recommendation 21

State, local, and federal governments and professional organizations should conduct outreach to physicians and nonphysician providers who serve VFC-eligible children and adolescents, to encourage those providers to participate in the VFC program if they currently do not. Outreach directed toward providers who serve adolescents and might not have provided vaccinations in the past (eg, obstetrician/gynecologists) is a particular priority.

Recommendation 22

States and localities should develop mechanisms for billing insured children and adolescents served in the public sector. The CDC should provide support to states and localities by disseminating best practices and providing technical assistance to develop these billing mechanisms (which may require additional resources not currently in the CDC immunization program budget). Furthermore, the NVAC urges states and localities to reinvest reimbursements from public and private payers in immunization programs.

Recommendation 23

Adequate funding should be ensured to cover all costs (including those incurred by schools) arising from ensuring compliance with child and adolescent immunization requirements for school attendance.

Recommendation 24

Shared public/private-sector approaches to help fund school-based and other complementary-venue child and adolescent immunization efforts should be promoted.