Policy Strategies to Increase Access to Prenatal Vaccines in Medicaid and CHIP: New White Paper

Below is an edited excerpt from a recent Manatt Health paper. Click here to read the full text.

Despite the demonstrated effectiveness of prenatal vaccines, uptake remains low. This puts mothersⁱ and babies at risk. Vaccines administered prenatally (i.e., during a pregnancy) provide protective antibodies to pregnant women and their unborn children. By receiving all federally recommended prenatal vaccines, pregnant women can reduce their risk of communicable diseases (such as influenza, COVID-19, or whooping cough) that would jeopardize both their own health and the health of their pregnancy. Moreover, they can protect their newborns from dangerous infections such as respiratory syncytial virus (RSV), for which a new vaccine was approved in fall 2023.

Prenatal vaccination rates are especially low among the low- and middle-income people covered by Medicaid and the Children’s Health Insurance Program (CHIP).ⁱⁱ These disparities may reflect in part lower reimbursement rates compared to commercial insurance, resulting in reduced access to providers who offer prenatal vaccines.ⁱⁱⁱ

In a new white paper, we review the current landscape of Medicaid and CHIP reimbursement for prenatal vaccines, informed by a recent assessment of relevant policies in all 50 states, plus Washington, D.C. and Puerto Rico. We examined policies for both fee-for-service (FFS) and managed care programs, with a focus on the following types of providers: physicians, advanced practice clinicians, pharmacists, and Federally Qualified Health Centers (FQHCs), updating and building upon the findings in our 2023 paper (which examined state policies between November 2021 and April 2022).

Our key findings include:

• Across all practitioner types, Medicaid and CHIP reimbursement for vaccine administration is typically much lower than under Medicare and private plans. Depending on practitioner type, the average Medicaid vaccine administration fee for youth ranges from 50–56% of the Medicare Part B rate for administering the flu vaccine. For adults, the average fee ranges from 37–49% of Medicare Part B.
• Taking into account the total reimbursement for vaccine administration and vaccine supply during a billable office visit, all states reimburse less than Medicare, and most states reimburse significantly less than Medicare, with particularly stark disparities for youth vaccinations (see chart below).
• Some states restrict coverage for vaccines administered by pharmacists:
   
  • We identified three states that exclude coverage under FFS for pharmacist vaccinations (KY, NE, and NJ). An additional four states cover adult vaccinations for pharmacists, but not vaccinations for youth under 19 (NH, VT, VA, and WV).
  • In the remaining states, some states only cover certain pharmacist-administered vaccines instead of covering the full set of vaccines that pharmacists are authorized to administer under state law. We identified seven states that excluded FFS coverage for prenatal RSV vaccines when administered by pharmacists (GA, IN, KS, KY, LA, SC, WV).

Comparison of Total Reimbursement for Fluzone and  Tdap Vaccinations (Administration + Supply) Under Medicaid FFS vs. Medicare, by Patient Age*

_{* Manatt Health researched publicly available Medicaid and CHIP policies in all 50 states, plus D.C. and Puerto Rico, between November 2023 and March 2024. With respect to Medicare, Flu vaccines are covered under Medicare Part B, while Tdap is covered under Medicare Part D. To calculate the Medicare composite rate for adults, we combined: (1) the 2024 Medicare flu vaccine administration fee (G0008); (2) the 2024 Fluzone supply fee (90686); and (3) the weighted average for Part D reimbursement of Tdap (90715), based on the 2022 rates for the Adacel and Boostrix vaccines (the more recent data available; note that Part D reimbursement combines both the administration and supply fees). For VFC youth, there is no Medicaid reimbursement for the supply. Therefore, we calculated a hypothetical Medicare composite using the Part B codes for: (1) administration of the flu vaccine (G0008) and (2) the non-vaccine-specific codes for administering a combination vaccine with counseling to youth age <19 (90460 for the initial component, plus 90461 for each additional component).}

Based on these findings, our paper describes policy strategies to improve prenatal vaccine access for Medicaid and CHIP enrollees:

1. Ensure adequate reimbursement for prenatal vaccinations
2. Optimize the value of the Vaccines for Children (VFC) program
3. Leverage managed care organizations (MCOs) to enhance prenatal vaccine access in states with managed care
4. Support state vaccinator capacity using policy levers outside Medicaid and CHIP

The table below details these policy priorities in more detail, including strategies for state policymakers, the federal Centers for Medicare & Medicaid Services (CMS), and the federal Centers for Disease Control & Prevention (CDC).

Policy Strategies to Promote Access to Prenatal Vaccines in Medicaid and CHIP

Click here to read the full report and findings.

_{ⁱ Although this paper will generally refer to “mothers” and “pregnant women,” the authors acknowledge that some pregnant individuals may not identify as women.
ⁱⁱ CDC, Influenza, Tdap, and COVID-19 Vaccination Coverage and Hesitancy Among Pregnant Women — United States, April 2023 (September 29, 2023),https://www.cdc.gov/mmwr/volumes/72/wr/mm7239a4.htm; CDC, Influenza and Tdap Vaccination Coverage Among Pregnant Women — United States, April 2020 (October 2, 2020), https://www.cdc.gov/mmwr/volumes/69/wr/mm6939a2.htm.
ⁱⁱⁱ The Medicaid and CHIP Payment and Access Commission (MACPAC), Vaccine Access for Adults Enrolled in Medicaid, Report to Congress on Medicaid and CHIP, 24–49 (March 2022), https://www.macpac.gov/wp-content/uploads/2022/03/Chapter-2-Vaccine-Access-for-Adults-Enrolled-in-Medicaid.pdf.}