Return to VFC State Immunization Project FAQs
- What are the statutory requirements for the VFC program regarding the vaccine administration fee?
Section 1928(c) (2) (C) (ii) of the Social Security Act (42 U.S.C. 1396s(c) (2) (C) (ii)) states:
"The provider may impose a fee for the administration of a qualified pediatric vaccine so long as the fee in the case of a federally vaccine-eligible child does not exceed the costs of such administration (as determined by the Secretary based on actual regional costs for such administration)."
Section 1928(c) (2) (C) (iii) of the Social Security Act (42 U.S.C. 1396s(c) (2) (C) (iii)) further provides that: "The provider will not deny administration of a qualified pediatric vaccine to a vaccine-eligible child due to the inability of the child's parent to pay an administration fee.
The Health Care Financing Administration
(HCFA), now the Centers for Medicare and
Medicaid Services (CMS), published
a notice of the federal regional administration
fee caps in the Federal Register on October
3, 1994 (59 FR 50235). The notice
also indicated that state Medicaid programs
could establish lower administration fees
for VFC vaccination of Medicaid children.
Except in the case of an inability to
pay, the notice further stated that VFC
providers can charge non-Medicaid federally
vaccine-eligible children (i.e., uninsured,
American Indian/Alaska Natives, and when
administered by an FQHC or RHC, underinsured
children) up to but not more than the
maximum regional administration charge
(if that charge reflects the provider's
cost of administration) regardless of
whether the state has established a lower
administration fee under the Medicaid
The administration fee caps do not apply to vaccination of state vaccine-eligible children. The VFC program does not have any authority over administration fees charged to state vaccine-eligible children or privately insured children.
State A’s Medicaid Agency has set the state Medicaid vaccine administration reimbursement at $10.00. The state’s regional administration fee cap is $15.00. A VFC-enrolled provider can expect to receive $10.00 for the administration of a vaccine to a VFC-eligible child enrolled in Medicaid. The VFC-enrolled provider can charge a maximum of $15.00 to a VFC-eligible child NOT enrolled in Medicaid. The VFC program does not regulate administration fees charged to private pay or privately insured patients.
- What group(s) of VFC eligible children can be charged an administration fee?
VFC providers can charge an administration fee directly to the parents of non-Medicaid VFC eligible children (i.e., uninsured, American Indian/Alaska Natives and underinsured children). VFC providers can charge non-Medicaid federally vaccine-eligible children up to but not more than the maximum regional administration charge.
- Who should pay the vaccine administration fee for Medicaid-eligible children?
The state Medicaid agency should be billed for the administration fee for Medicaid-eligible VFC children immunized by a Medicaid-enrolled VFC provider. State Medicaid agencies establish their own policies and administration fees that may be lower than the regional maximum amounts established in 1994. For Medicaid VFC-eligible children, the state Medicaid agency determines and CMS approves the reimbursable amount for their fee-for-service and managed care enrolled recipients. If the provider bills Medicaid more than the allowable rate, the provider will be reimbursed only the allowable rate and not the amount billed. The difference between the allowable rate and the amount billed cannot be collected from the parents of the child.
- What are the administration fee requirements for insured children who have private health insurance benefits that include immunization coverage?
The VFC administration fee caps only apply to VFC eligible children and do not apply to privately insured children.
- What is involved in raising the reimbursement rate for VFC vaccine administration by Medicaid at the state level?
State Medicaid agencies, through processes that vary from state to state, may raise the VFC administration fees payable to Medicaid providers for vaccinating Medicaid eligible children up to the regional fee cap that was established for each state in 1994. Should a state consider its CMS-imposed cap to be too low, CMS and CDC should be contacted to discuss potential revision of the fee cap. Because so few state Medicaid agencies are reimbursing at the maximum regional charge, the current fee structure will remain in effect until further notice.
- Is the administration fee based on per shot or per antigen?
Providers bill according to CPT codes that are based on each vaccine (type of immunization) administered. Reimbursement through Medicaid varies by state. Some state Medicaid agencies reimburse a vaccine with multiple antigens at a higher rate than a single antigen vaccine. Some states limit the amount of administration fees reimbursed per visit. Please check with the stateMedicaid agency to determine how the VFC administration fees are reimbursed. State Medicaid agencies cannot eliminate reimbursement of an administration fee because of how the vaccine is administered (i.e. injection versus orally administered).
For non-Medicaid VFC eligible children (i.e., Alaska Natives/Native Americans, uninsured and underinsured) the administration fee is based on vaccine dose (shot) not the number of antigens contained in a vaccine dose (shot). The administration fee charged to a non-Medicaid VFC eligible child cannot exceed the maximum regional charge except in universal-purchase states and then only if certain conditions are met. See the next question.
- How does the CMS maximum regional charge for vaccine administration relate to universal-purchase states?
The October 1994 Federal Register notice gives universal purchase states (states in which the vaccines are purchased by the state for all children in the state) the right to develop administration fees that differ from those established by CMS, provided they are reasonable. Therefore, universal purchase states are provided the flexibility to accept the maximum charges established by the Secretary or develop their own maximum charges. The maximum charges must be developed utilizing a reasonable methodology based on VFC section 1928(c)(2)(C)(ii) of the Social Security Act. The amount of the cap (maximum fee) is not required to be set in state law. However, the authority to set an amount must be based in state law. In either case, CMS gives state Medicaid agencies the option to establish and apply vaccine administration fees that are lower than the specified maximum regional charges if they provide assurances that Medicaid children have access to immunizations to the same extent as the general population.
- How does a VFC-enrolled provider who is not already a Medicaid provider file for Medicaid reimbursement for vaccine administration?
It is necessary to be a Medicaid provider in order to receive payment from Medicaid for vaccine administration services provided to Medicaid-eligible children. Providers should consult the state Medicaid agency about the procedures necessary to become a Medicaid provider.
- Does the VFC program require that a sign be posted in all vaccine providers’ offices that states “No VFC eligible child may be denied federally-supplied vaccine due to the inability to pay the administration fee”? May we use some other communication tools, such as a flyer that allows for a few paragraphs of explanation?
There is nothing in the VFC legislation that mandates a posted sign in provider offices. Other means of communication may be used.
- Can a provider refuse to administer VFC vaccine to VFC-eligible child?
Section 1928 (c)(2)(C)(iii) of the Social Security Act states, “The provider will not deny administration of a qualified pediatric vaccine to a vaccine-eligible child due to the inability of the child’s parents to pay an administration fee.” This requirement must be met by all VFC providers. However, the VFC legislation does not require providers to honor vaccine requests by VFC-eligible children who “walk in” for immunizations only and are not established patients in the practice.
page last modified on September 14, 2006