pediatrics
December 2009, VOLUME124 /ISSUE Supplement 5

Role of Health Insurance in Financing Vaccinations for Children and Adolescents in the United States

  1. Angela K. Shen, MPHa,
  2. John Hunsaker, MPPb,
  3. Julie A. Gazmararian, PhD, MPHc,
  4. Megan C. Lindley, MPHd,
  5. Guthrie S. Birkhead, MD, MPHe,f,g
  1. aNational Vaccine Program Office, US Department of Health and Human Services, Washington, DC
  2. bDepartment of Clinical Affairs and Strategic Planning, America's Health Insurance Plans, Washington, DC
  3. cDepartment of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia
  4. dNational Center for Immunization and Respiratory Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia
  5. eOffice of Public Health, New York State Department of Health, Albany, New York
  6. fDepartment of Epidemiology, School of Public Health, University at Albany, Albany, New York
  7. gNational Vaccine Advisory Committee, Washington, DC

Abstract

OBJECTIVE: The goal was to elicit perspectives of selected health insurance plan medical or quality improvement directors regarding factors related to coverage and reimbursement and perceptions of financing as a barrier to child and adolescent immunization.

METHODS: Medical or quality improvement directors from 20 plans selected by America's Health Insurance Plans were invited to complete an online survey in July 2007. Respondents who agreed to follow-up interviews were invited to participate in telephone interviews conducted by Centers for Disease Control and Prevention staff members in August 2007.

RESULTS: Fifteen plans (representing >67 million enrollees) responded to the online survey. All respondents covered all Advisory Committee on Immunization Practices–recommended child and adolescent vaccines in all or most products. Advisory Committee on Immunization Practices recommendations were the most commonly cited criteria for coverage decisions (86.7%) and coverage modifications (100%). Factors affecting reimbursement that were cited most often were manufacturer's vaccine price (80%) and physician feedback (53.3%). In follow-up interviews with 10 self-selected respondents, manufacturer's price (7 of 10 plans) and physician feedback (4 of 10 plans) were identified as the most-important factors affecting reimbursement. Respondents said that reimbursement delays were most commonly attributable to providers' claim submission errors or patient ineligibility. Some respondents thought that vaccine financing was a barrier (4 of 10 plans) or somewhat a barrier (2 of 10 plans) to providing immunizations; others (4 of 10 plans) did not.

CONCLUSION: Although these data suggest that health insurance coverage for recommended vaccines is high, coverage is not universal across all products offered.

  • cost
  • coverage
  • health insurance
  • immunization
  • reimbursement
  • vaccine
  • vaccination

In 2006, the National Vaccine Advisory Committee (NVAC) formed a Vaccine Financing Working Group to examine the current state of the US vaccine financing system, to highlight challenges in the system, and to make recommendations to ensure access to vaccinations for children and adolescents without financial barriers.15 NVAC was concerned that financial challenges might increase gaps in immunization rates and therefore protection against vaccine-preventable diseases.26 NVAC sought input from key stakeholders, such as health care providers, consumers, vaccine manufacturers, employers, and payers, including private health insurance plans, to inform its process of providing guidance to the US Department of Health and Human Services.

Health insurance plans play an essential role in the vaccine financing system, providing insurance through either individual or group purchases (eg, employers or state programs). Group purchasers select from a wide range of benefit packages designed by health insurance plans, which vary in the scope of covered benefits and consumer cost-sharing. The primary types of health insurance products (eg, health maintenance organizations, preferred-provider organizations, or point-of-service plans) available to purchasers manage health care services and costs in different ways.

Private-sector vaccine purchases account for 45% to 50% of the pediatric vaccines sold in the United States each year (Centers for Disease Control and Prevention, unpublished data, 2007). Health care providers in the private sector purchase and administer vaccines and are reimbursed subsequently, by parents, health insurance plans, or state programs, for vaccine purchase and administration. Children and adolescents who receive immunization benefits either pay out of pocket or have coverage under private health insurance plans or public programs. However, some children7,8 and adolescents9 who have private health insurance may not have coverage for ≥1 vaccine.

Although most research has focused on the public sector,10,11 more studies are exploring vaccine provision in the private sector.12,13 To address knowledge gaps about how private health plans determine vaccination coverage and reimbursement policies, the National Vaccine Program Office, on behalf of NVAC, collaborated with America's Health Insurance Plans (AHIP), the national trade association of private health insurance plans, to survey selected AHIP members regarding their immunization policies and practices. The study sought to assess the plans' perspectives on (1) factors related to coverage decisions and reimbursement rates, (2) factors affecting timely reimbursement, (3) perceptions of financing as a barrier to child and adolescent immunization, and (4) suggested steps to address any financing barriers.

METHODS

Sample Selection

By using the Atlantic Information Services Directory of Health Plans: 2007,14 which lists 631 health insurance plans, AHIP identified 20 member plans that were responsive to previous AHIP surveys and were representative of 5 prospectively defined categories representing common plan types. Plans selected included (1) 6 large national plans having ≥5 million enrollees and operating in ≥10 states, (2) 7 large state or regional plans having enrollment between 200000 and 4999999 and operating in ≤10 states, (3) 4 small plans having enrollment of <200000, (4) 1 large plan with preferred-provider organization network products, and (5) 2 single-state Medicaid plans. Participation was voluntary and included 2 components, that is, an online survey and a follow-up telephone interview.

Survey and Interview Administration

AHIP sent an initial e-mail invitation in June 2007 to the chief medical officers or quality improvement directors of the 20 selected plans, requesting their participation in a survey regarding their company's vaccination coverage and reimbursement policies (Appendix 1). A follow-up e-mail with the link to the online survey was sent to nonresponders by a National Vaccine Program Office-contracted, third-party vendor, who executed the survey through an online survey tool and managed the data. Survey respondents were asked whether they would be willing to be contacted for a follow-up interview (Appendix 2). In July and August 2007, Ms Lindley conducted telephone interviews with online survey respondents who agreed to follow-up interviews. The third-party vendor took notes on the responses. Interviews were scheduled for 30 minutes. Respondents were allowed to select multiple answers to survey questions and to provide open-ended responses. Questions asked in the interviews were both multiple-choice (based on responses from the survey) and open-ended, with prompts to solicit more-detailed information when appropriate.

APPENDIX 1

Online survey tool. NVPO indicates National Vaccine Program Office; HMO, health maintenance organization; PPO, preferred-provider organization; POS, point of service; FDA, Food and Drug Administration; AAP, American Academy of Pediatrics; CPT, Current Procedural Terminology; MMWR, Morbidity and Mortality Weekly Report; E & M, evaluation and management.

APPENDIX 2

Follow-up interview guide. CDC indicates Centers for Disease Control and Prevention.

Data-Collection Instruments

A 13-question, online, multiple-choice survey was developed by the Vaccine Financing Working Group and was reviewed by AHIP. The survey asked respondents about the scope of their plan's coverage for child (0–6 years) and adolescent (7–18 years) vaccines, factors used by plans for determining and modifying vaccine coverage, factors related to vaccine reimbursement, and strategies to ensure timely reimbursement.

Telephone interview questions were designed to clarify and to explore responses from the online survey. Topics included distinctions between reimbursement policies for vaccine purchase and vaccine administration, the relative importance of various factors in determining reimbursement, provider feedback regarding reimbursement levels, perceptions of vaccine financing as a barrier to childhood immunization, and suggested steps to address any financing barriers. A standardized list of interview questions was customized on the basis of online survey responses.

Data Analysis

Responses from all plan categories were aggregated and then analyzed. The number of enrollees represented by the responding health plans was calculated. Qualitative responses were grouped in 4 thematic areas, namely, factors related to coverage decisions, factors affecting reimbursement rates, factors related to payment timing issues and potential steps to address those issues, and perceptions of financing as a barrier to immunizations and steps that might address that barrier.

RESULTS

Respondent Characteristics

The online survey was completed by 15 (75.0%) of 20 invited plans, which covered >67 million enrollees in both commercial and Medicaid programs. Responses were received from 5 (83.0%) of 6 large plans, 5 (71.4%) of 7 state or regional plans, 3 (75.0%) of 4 small plans, and both Medicaid plans (100.0%). Product lines represented in these results included commercial health maintenance organizations, commercial preferred-provider organizations, commercial point-of-service plans, Medicaid, and Medicare (for children with disability coverage).

Ten plans participated in the follow-up interviews. Respondents from 4 plan categories were interviewed, that is, large plans (4 plans), state or regional plans (2 plans), small plans (2 plans), and Medicaid plans (2 plans). Responses reported below were collected from the online survey unless noted otherwise.

Factors Related to Coverage Decisions

What Factors Are Used to Determine Inclusion of Vaccines in Benefit Packages?

Advisory Committee on Immunization Practices (ACIP) recommendations were selected most commonly by respondents (86.6%) as a factor used in determining inclusion of vaccines in a particular benefit plan design. Other frequently cited factors included US Food and Drug Administration approval, state laws, the contract between the purchaser (eg, employer) and the health insurance plan, and review by a pharmacy and therapeutics committee (responsible for the promotion of rational, safe use of effective, pharmacy-related products, such as drug therapy and vaccines, within an institution such as a health insurance plan or hospital) (Table 1). A health insurance plan's pharmacy and therapeutics committee is responsible for evaluating a formulary of drugs, including vaccines, for inclusion as a covered benefit and recommending to the insurance plan the level at which the covered benefit should be paid.

TABLE 1

Most Commonly Reported Factors for Determining Vaccine Coverage as Benefit

Are All ACIP-Recommended Vaccines for Children and Adolescents Covered Benefits?15

At the time of the survey, all respondents indicated that all of the recommended child and adolescent vaccines were covered for all or most products offered (Table 2).

TABLE 2

Reported Health Plan Coverage of ACIP-Recommended Vaccines

How Often Are Vaccine Coverage Policies Reviewed?

More than one half (53.3%) of respondents reported reviewing coverage policies after every ACIP meeting (meetings are held 3 times per year).

What Factors Could Affect Modification of Contracts Between the Health Insurance Plan and Providers in the Middle of a Contract Period?

Respondents from all plans said changes in ACIP recommendations in the middle of a contract period might affect vaccination benefits coverage for the rest of the contract period. Respondents did not quantify what proportion of their products might accommodate such midcontract changes. Other cited factors included vaccine shortages (eg, when a vaccine is unavailable because of a shortage, a plan could modify a contract to include coverage for a substitute vaccine not previously covered, as was the case with live, attenuated, inactivated influenza vaccine for inactivated influenza vaccine), Food and Drug Administration action, and state regulatory changes (Table 1).

Factors Affecting Reimbursement Rates

What Factors Need to Be in Place for a Physician to Be Reimbursed for Providing Vaccination Services?

The availability of Current Procedural Terminology codes (93.3%) and the assignment of these codes to a new vaccine (93.3%) were the most common responses. For the providers to bill for a vaccine, there must be a code to submit a bill.

What Factors Are Considered When Determining or Adjusting Reimbursement Rates?

Manufacturer's price for the vaccine was the most frequently cited response, followed by physician feedback, the price of services related to immunization administration, market forces, and geographic location (Table 1).

Follow-up Interview Findings on Reimbursement Rates

Which Factors Identified Were Most Important for Determining Reimbursement for Vaccines and Vaccine Administration?

The manufacturer's price for the vaccine was cited by 7 of 10 respondents as the most-important factor affecting the reimbursement rate for vaccine purchase. Physician feedback was cited by 4 of 10 respondents as the most important factor affecting vaccine administration reimbursement (Table 3).

TABLE 3

Most-Important Factors in Determining Vaccine and Vaccine Administration Reimbursement

How Often Are Reimbursement Rates Modified?

Responses varied from “monthly” to “biannually”; ≥1 respondent indicated that the plan modified rates “as new information becomes available.” Some respondents indicated that vaccine purchase and administration rates were modified at the same time. Respondents who indicated that rates were modified at different times noted that vaccine administration rates were modified less frequently than reimbursement for vaccines.

How Long Does It Take to Begin Paying Claims for Newly Covered Vaccines?

Various factors characterized above (eg, ACIP recommendations) came into play during decision-making. Respondents stated that, once a plan decided to cover a vaccine as a benefit, claims began to be paid anywhere from the same day (5 respondents) to 45 days after coverage was determined.

Are There Mechanisms in Place to Modify Contracts Between the Plan and Providers?

Respondents stated that communicating in advance with pharmaceutical companies to learn of available new vaccines and holding appropriate monthly committee meetings (eg, pharmacy and therapeutics committee) were mechanisms for including a vaccine in benefit packages during the middle of a contract period.

Are Provisional ACIP Recommendations Sufficient to Prompt Coverage of New Vaccines?

Four of 10 respondents answered that an ACIP provisional recommendation (approved by ACIP vote and posted at www.cdc.gov/vaccines/recs/provisional/.; recommendations do not become official until they are accepted by the Centers for Disease Control and Prevention director and published in the Morbidity and Mortality Weekly Report) was sufficient for their plans to cover a new vaccine as a benefit, 2 stated that they waited for Morbidity and Mortality Weekly Report publication, and 3 stated that their responses would vary depending on the vaccine. For example, 2 respondents mentioned that, if a vaccine was widely anticipated or was receiving coverage in the media (eg, human papillomavirus vaccine), then the typical requirements or time line for approval might be modified. One respondent mentioned that the plan had the ability to apply coverage retroactively to the Food and Drug Administration approval date.

Several respondents mentioned that, although the ACIP vote might not be sufficient for coverage, their plans used information provided at ACIP meetings to begin the process of preparing coverage of a new vaccine. This preparation decreased lag time in coverage once the recommendation was published in the Morbidity and Mortality Weekly Report.

Factors Related to Payment Timing Issues and Potential Steps to Address Those Issues

What Are the Most Common Reasons for Delays in Payment?

The majority of respondents (73.3%) said that delays in reimbursement were most commonly attributable to claim submission errors by providers or patient ineligibility.

What Can Providers and Plans Do to Minimize the Time Between Claim Submission and Reimbursement?

Respondents said that providers should confirm that patients are eligible (ie, enrolled in the plan) and that vaccination is a covered benefit in the plan, should submit accurate complete claims, and should submit claims electronically. All respondents indicated that the ability to process claims electronically minimizes the time from claim submission to reimbursement. Respondents identified steps that health insurance plans could take to facilitate reimbursement, including ensuring that information about patient eligibility and covered services is available online and providing rapid feedback regarding issues that delay payment.

What Is the Average Claims-Processing Time From Claim Receipt to Provider Reimbursement?

All respondents stated that their answers reflected “clean claims” (ie, for eligible services and without errors). Five respondents processed claims within 30 days, 4 respondents processed claims within 15 days, and 1 respondent did not know. All respondents stated that electronic claims filing and processing helped decrease the time from claim receipt to provider reimbursement. Some respondents already receive and process 90% of their claims electronically; others are closer to 50%. Respondents with 90% electronic claims noted that they are working to reduce claims payment time to 1 to 3 days.

Follow-up Interview Findings on Perceptions of Financing as a Barrier to Immunization and Potential Steps to Address That Barrier

Is Vaccine Financing a Barrier to Childhood Immunization?

Some respondents (4 of 10 plans) perceived vaccine financing to be a barrier, some (2 of 10 plans) perceived financing to be somewhat of a barrier, and some (4 of 10 plans) did not perceive financing to be a barrier.

What Are the Major Reasons?

Respondents who perceived financing as a barrier or somewhat of a barrier to childhood immunization cited financial challenges for physicians providing vaccinations, including high storage fees, overhead costs, and inadequate reimbursement.

What Are Possible Solutions to the Problem?

Respondents suggested various solutions to address direct and indirect costs of providing immunization, including vaccine-related expenses (eg, vaccine purchase and storage) and immunization administration expenses (eg, medical supplies). These solutions included (1) instituting centralized vaccine purchasing by states or insurers, so that providers would not need to pay for vaccine inventory up front, (2) applying the American Academy of Pediatrics recommendations to ensure that reimbursement covers direct and indirect costs, including return investment on vaccine inventory,16 and (3) listening to providers to ensure adequate reimbursement.

Have Health Care Providers Expressed Dissatisfaction With Vaccine Purchase Reimbursement Rates?

Six respondents answered yes and named newer, “expensive” vaccines, most frequently human papillomavirus vaccine.

Have Health Care Providers Ever Expressed Dissatisfaction With Vaccine Administration Reimbursement Amounts?

Five respondents had heard provider dissatisfaction, 4 had not, and 1 had rarely heard dissatisfaction with vaccine administration reimbursement.

How Can Provider Satisfaction With Administration Reimbursement Rates Be Improved?

Respondents suggested ways to improve provider satisfaction indirectly by shifting vaccine purchasing to states or the insurer and communicating to providers the rationale for changes in reimbursement rates.

Are Vaccines Discussed Specifically in Contracts With Providers?

Five respondents answered yes. Several stated that contract language requires providers to administer set amounts of required vaccines, as listed in the contract. One respondent stated that contracts require providers to administer vaccines but do not mention specifically which vaccines or how many.

DISCUSSION

Our survey and follow-up interviews help to provide insight into vaccine coverage and reimbursement policies of some health insurance plans. Understanding the factors that contribute to decision-making about benefit packages available to health plan members is important for addressing challenges to the private-sector vaccine financing system and helps ensure that financing is not a barrier to providing ACIP-recommended vaccinations.

ACIP recommendations (which are based on careful review of scientific data, including disease morbidity and mortality rates, vaccine safety and efficacy, and cost-effectiveness) clearly play a critical role in influencing coverage benefits and subsequent modifications. ACIP works closely with many liaison organizations, including AHIP, to develop evidence-based recommendations for vaccine use that are harmonized among professional organizations, including the American Academy of Pediatrics and the American Academy of Family Physicians.17 Although all respondents indicated that their plans covered all vaccines recommended by ACIP in all or most of their products, not all products included coverage for all recommended vaccines.

Immunization is consistently a top-ranked, clinical preventive service in the United States. These rankings are designed to help decision-makers, including public health agencies and employers, allocate limited resources, informing consumers about high-quality and high-value health care services.18 In the United States, employer-sponsored insurance is the leading source of health insurance, covering ∼158 million nonelderly people.19 Purchasers choose from a range of benefits offered by the health insurance plan, and not all products include coverage for all vaccines. Because benefit plans are designed and developed on the basis of purchaser demand, employers and consumers play important roles in ensuring access to vaccines.

We sought to determine whether vaccine providers' perceptions of payment timing issues were corroborated by health insurance plans and, if so, to understand the causes of any delays. Respondents reported discrete, identifiable factors as the main causes of payment delays, that is, claim submission errors and patient ineligibility. This suggests that working with health care providers to improve claim submissions might decrease the time from claim submission to reimbursement and might improve the stability of provider practices. Health insurance plans and medical professional organizations can play roles in educating health care providers on appropriate billing practices.

Balancing the concerns of multiple stakeholders involved in the vaccine financing and delivery system while simultaneously reducing financial barriers to all US individuals receiving ACIP-recommended vaccinations is a continuing challenge. One suggestion put forth by 2 respondents who thought that vaccine financing is a barrier to immunization proposed shifting the costs of vaccine purchases from health care providers to other stakeholders (eg, states or insurers). This idea highlights the interrelatedness of the stakeholders involved in the US immunization system. Because vaccine manufacturers oppose a universal purchase system regardless of payer,4,20,21 this may not be a realistic solution. Manufacturers assert that they rely on the current pricing structure in the public- and private-sector market as a source of revenue and a source of funds to invest in the development of new vaccines.21

There are several limitations to this study. First, it was conducted with a small convenience sample of plan representatives who had responded to previous AHIP surveys, and selection bias might limit the representativeness of the responses. However, respondents represented diverse health insurance plans that covered 67 million individuals, with variations in enrollment size, geographic setting, and organizational structure. Other limitations for interpretation of the study findings are the general nature of the questions and the fact that responses could not be analyzed for each product line the health insurance plans offered. Finally, responses were aggregated from all plan categories. This might have masked differences between categories of responding health insurance plans. Despite these limitations, our results provide a snapshot of information from representatives of health insurance plans covering a significant proportion of the population.

CONCLUSIONS

Many factors influence the coverage and reimbursement decisions of the health insurance plans whose employees participated in this survey. Although these data suggest that health plan coverage for ACIP-recommended vaccines is high, coverage for all vaccines is not universal in all of the products offered. Additional efforts may be needed to educate purchasers of health insurance (both individuals and employers) about the value and cost-effectiveness of vaccines.22 The results of this analysis helped inform the recent NVAC recommendations to ensure delivery of all ACIP-recommended vaccines to all children and adolescents without financial barriers.23 They also provide a framework for researchers to explore these issues in a larger context.

Acknowledgments

We thank Carmella Bocchino, Barbara Lardy, Alan Rosenberg, MD, German Veselovskiy, and Jenny Salesa for their invaluable assistance.

Footnotes

    • Accepted August 25, 2008.
  • Address correspondence to Angela K. Shen, MPH, US Department of Health and Human Services, National Vaccine Program Office, 200 Independence Ave, SW, Room 717H, Washington, DC 20201-0004. E-mail: angela.shen{at}hhs.gov
  • At the time this paper was prepared Mr Hunsaker was at America's Health Insurance Plans; he is now an MBA candidate at Brandeis University.

  • The findings and conclusions in this report are those of the authors and do not necessarily represent the views of America's Health Insurance Plans, its staff members, or its member organizations, the US Centers for Diseases Control and Prevention, or the US Department of Health and Human Services. Respondents who participated in the survey and interviews discussed in this article expressed solely their views and not the official positions of their affiliated organizations or America's Health Insurance Plans.

  • Financial Disclosure: The authors have indicated they have no financial relationships relevant to this article to disclose.

ACIP—Advisory Committee on Immunization PracticesAHIP—America's Health Insurance PlansNVAC—National Vaccine Advisory Committee

REFERENCES