Vaccines
for Children Program (VFC)
For Providers |
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Aspects
of Medicaid and
How Medicaid & VFC work together? |
On
this page:
If
you are a Medicaid Provider, there are many
aspects of Medicaid that you should be aware
of and how Medicaid and the VFC Program work
together.
By
enrolling as a VFC Provider, you will be able
to provide free vaccines to this entire childhood
cohort while saving yourself valuable operating
capital.
By
far the largest category of children eligible
for the VFC program is Medicaid-enrolled children.
A
Medicaid Primer
Title
XIX of the Social Security Act is a Federal/State
entitlement program that pays for medical assistance
for certain individuals and families with low
incomes and resources. This program, known
as Medicaid, became law in 1965 as a cooperative
venture jointly funded by the Federal and State
governments (including the District of Columbia
and the Territories) to assist States in furnishing
medical assistance to eligible needy persons.
Medicaid is the largest source of funding for
medical and health-related services for America's
poorest people, including disadvantaged children.
Within
broad national guidelines established by the
Federal government, each State Medicaid Program:
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Establishes its own eligibility standards,
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Determines the type, amount, duration, and
scope of services,
-
Sets the rate of payment for services; and
-
Administers its own program.
Thus,
the Medicaid program varies considerably from
State to State. However, one thing that remains
constant from State to State regardless of
their programmatic policy differences, is that
all State Medicaid programs recognize and encourage
their participating physicians to enroll in
the VFC Program.
Medicaid
State Plan Requirements
While
CDC has the lead responsibility for policy
development and implementation of the VFC program,
the VFC program is contained in the Medicaid
law and is funded by the Federal Government
through the Centers for Medicare and Medicaid
Services (CMS), Medicaid program. Each State
Medicaid program must file a Medicaid State
plan amendment covering its Pediatric Immunization
Program in order to receive Federal funds to
operate its Medicaid program and to receive
vaccines from the VFC program.
Managed
Care
Medicaid
managed care continues to be a preferred model
to serve children enrolled in the Medicaid
program. Approximately 54 percent of Medicaid
beneficiaries are covered under some type of
managed care plan and about 55 percent of those
are children.
Most
children who are enrolled in these plans are
required to receive care from designated providers.
Otherwise, the Federal government will not
reimburse the service. This requirement is
commonly called a “lock-in” requirement.
If lock-in applies, Medicaid and the plan may
refuse to pay a vaccine administration fee
if a VFC provider who is not a plan provider
provides an immunization to that child.
There
are exceptions to the above statement. Some
States have written conditions into their contracts
with managed care organizations (MCO’s)
requiring the plan, or the State, to pay immunization
administration fees to non-plan providers.
Your State Medicaid agency should be able to
advise if this is the case in a particular
situation.
It
may also be possible for a public provider
to directly negotiate an agreement with an
MCO to serve its patients and to bill the MCO
for the vaccine administration fee when that
MCO’s enrollees are immunized at the
public health clinic. In this case, the public
health clinic is part of the MCO’s network
and negotiated services are considered to be
in-plan services.
There
are also other varieties of plans that do not
require the patient to receive all care from
plan providers, such as Preferred Provider
Organizations (PPO’s).
For
children enrolled in Medicaid, the most common
plan is the “Primary Care Case Management
(PCCM)” model. About 16.5 % of Medicaid
recipients who participate in managed care
arrangements are enrolled in PCCM’s.
In
this model, primary care physicians are assigned
to each participating Medicaid child. In order
to receive care from a specialist, the primary
care physician must refer the child. For these
services, the physician is usually paid a small
monthly case management fee, usually about
$5-$8. However, the physician is paid on a
fee-for-service (FFS) basis for all other covered
medical services. Medicaid enrolled children
who are enrolled in PCCM plans are expected
to receive primary care from their primary
care physician, but are not necessarily required
to do so.
For
example, some physicians who are participating
in a PCCM routinely refer patients to the Health
Department for immunization. Consult
your State Medicaid agency to determine whether
a VFC participating physician who is not that
child’s primary care physician may bill
Medicaid for the vaccine administration fee.
Fee
Caps on Vaccine Administration
The
legislation that created the VFC program requires
that the Secretary, Department of Health and
Human Services, establish a limit on the amount
of money that a provider can charge for the
administration of vaccines to VFC-eligible
children.
An
initial Federal
Register notice setting forth the interim
maximum amounts a participating provider may
charge for administering a vaccine to a VFC
child was published on October 3, 1994.
The
administration fees were established on the
basis of national charge data that were obtained
under Federal contract with the American Academy
of Pediatrics. Charge data were used rather
than cost data, because accurate, useable nationwide
cost data were not available nor could CMS
obtain them by October 1, 1994.
Recognizing
the importance of utilizing cost data in developing
the regional maximum charges, CMS published
the interim maximum charges based on charge
data with the intention to conduct a study
to accumulate cost data and with the goal to
revise the maximum charges based on cost.
What
is a Medicaid State plan and a plan preprint?
The
State plan is the document by which the State
certifies that it will comply with all Federal
requirements for Medicaid. Some of the requirements
are identical for all States, and some permit
the State to choose certain options. The State
plan preprint is the document the State completes
in order to certify compliance, and to indicate
chosen options. In order to be eligible to
receive federal matching funds (Federal Financial
Participation) to operate its Medicaid program,
each State must agree to comply with all parts
of the State Medicaid plan on file with CMS.
The
portion of the State plan that covers VFC,
“State Requirements for Operation of
a Pediatric Immunization Program,” is
only one part of a much larger State plan for
Medicaid, covering all aspects of the program.
No matter which State agency operates the VFC
program, the State government is ultimately
responsible for seeing to it that its agencies
comply with the Medicaid State plan requirements.
As
part of the state plan reprint covering the
VFC program, States are required to report
the administration fee paid for children who
are Medicaid-enrolled. Changes to reimbursement
rates should also be reported. This information
is made available to the public on the VFC
home page.
How
can State Immunization Projects/State Medicaid
agencies help you?
It
is essential that State Immunization Projects
and State Medicaid agencies develop a good
working relationship with participating physicians
in order for the VFC program to succeed in
reaching and vaccinating children.
Since
a substantial proportion of children under
5 years of age are enrolled in Medicaid, and
the majority of vaccinations are due in the
first two years of life, the majority of the
children served by VFC will be Medicaid eligible.
However,
questions about Medicaid eligibility will invariably
arise. Immunization
project staff should have pre-existing arrangements
with Medicaid agencies to properly reply or
to refer queries.
It
is the responsibility of the State Medicaid
agency to enroll children in Medicaid. However,
because the VFC program will serve many children
who may not be aware of their potential eligibility,
the immunization staff should work with the
State Medicaid agency to develop referral procedures.
What if a parent/guardian
does not know whether a child is enrolled with
Medicaid?
A
“yes” response to Medicaid enrollment
is sufficient for a child to qualify for the
VFC program. There
is no requirement for verification of the “yes”
answer.
Providers
routinely screen for Medicaid eligibility,
and when you do, that screening automatically
relates to the VFC eligibility status of the
child.
However,
a parent/guardian may present a child for vaccination
and say, “I don’t know if the child
is enrolled in Medicaid.” If the patient
is judged to be without health insurance, and
their Medicaid eligibility remains in question,
providers are encouraged to vaccinate these
children and refer them to a State Medicaid
Agency to determine their status.
Such
referrals will broaden the range of health
benefits for those children determined to be
Medicaid eligible. Accordingly, health officials
are urged to consult State Medicaid officials
for assistance. Determine one or more resource
points in the Medicaid agency where queries
can be answered as they arise. One recommendation
is to develop a reference list of common problems
with resolutions that apply in your State.
FAQs/Other Eligibility Issues
Question:
Our
State covers children 19 and 20 years of age
under the Medicaid EPSDT program. Are these
children eligible for vaccine purchased by
the VFC program?
Answer:
No. The VFC law defines eligible children
as those 18 years of age and under. Medicaid
would be responsible for providing necessary
vaccination for EPSDT-eligible persons 19-20
years of age. Consult your State Medicaid
agency for further details.
Question:
How
does a VFC program registered provider, who
is not already a Medicaid provider, file for
Medicaid reimbursement for the vaccine administration?
Answer:
A VFC program registered provider is not
required to become a Medicaid provider in
order to receive publicly purchased vaccine.
If the child is uninsured or underinsured,
billing arrangements are made between the
parent and the provider. The provider cannot
charge for the vaccine supplied by public
sources. However, it is necessary to become
a Medicaid provider in order to receive payment
from Medicaid for vaccine administration
services provided to Medicaid eligible children.
Consult your State Medicaid agency about
the procedures necessary to become a Medicaid
provider.
Question:
Can
a State require Medicaid providers to become
VFC program registered providers, in order
to ensure that Medicaid eligible children receive
vaccine under the VFC program?
Answer:
Yes, your State Medicaid agency does have
the option to require participation in the
VFC Program. Some state agencies do not specifically
require Medicaid providers to register as
VFC providers, but they may refuse to cover
the cost of vaccines that are obtained through
private sources. It is to the benefit of
the Medicaid agency to require provider participation
in the VFC program because of reduced vaccine
costs.
Question:
Are
children who are enrolled in the State’s
Child Health Insurance Program eligible for
VFC?
Answer:
If the State has chosen the option of expanding
its’ Medicaid program under SCHIP,
the children are Medicaid-enrolled and may
be served by the VFC program as are all other
Medicaid-enrolled children.
If
the State has established an SCHIP program
that is not a Medicaid expansion, the children
who are enrolled are considered insured and
do not qualify for VFC vaccine.
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