The Impact of State Medicaid Policies on Adult Vaccination Post Affordable Care Act Implementation

Background: Medicaid rules permit each state to determine which adult vaccines will be covered, the cost-sharing policy for adult vaccination services, provider reimbursement policy, and the settings where vaccines may be administered. Aside from coverage and cost-sharing policy variability across the country, provider reimbursement remains a large challenge to adult immunization services. Evidence shows that pregnant women with Medicaid insurance have lower rates of Tdap vaccination than those women who are privately insured. This study investigates the differences in policies in both fee for service and managed care arrangements post ACA implementation.

Methods:

1. Statutory & regulatory codes of all 50 states and DC were collected and relevant laws were analyzed and coded based on characteristics of the provisions.
2. Attorney identified and reviewed all publicly available material relating to benefit coverage, cost-sharing, and payment for adult vaccination under Medicaid from all 50 states and DC.
3. PHLP attorney conducted interviews of state Medicaid Directors. Questions addressed coverage, cost-sharing, and reimbursement policies in FFS and MCO arrangements and examined what factors influence policy design in and how immunizations are promoted thru Medicaid.

Results: Due to ACA, 32 states & D.C. implemented an expansion and 19 haven't. Those adults who now receive insurance via expansion have access to all ACIP adult vaccinations with no cost-sharing. 14 of these states and one non expansion state cover all Medicaid enrollees. There are 35 states &DC that have traditionally enrolled Medicaid adults where coverage may not exist or cost-sharing does exist. Payment also varies &in many cases reimbursement falls below the private sector payment resulting in providers who are unwilling to take a financial loss on providing vaccinations &facilities not receiving payment for vaccination services.

Conclusion: Many factors may impact adult immunizations some occur before a patient has the opportunity to choose to vaccinate. Sometimes providers are taking financial losses by vaccinating. Coverage and cost-sharing barriers still exist for non-expansion adults. Results from this study can help inform Medicaid polices &provide Medicaid programs insight into other policies around the country.