How to Increase Access to Prenatal Vaccines for Medicaid Beneficiaries

Solidifying access to prenatal vaccines can help minimize maternal health disparities for pregnant people enrolled in Medicaid and the Children’s Health Insurance Program (CHIP). A white paper from Manatt Health detailed how these programs cover prenatal vaccines and how states can facilitate access to the critical services.

The Centers for Disease Control and Prevention (CDC) Advisory Committee on Immunization Practices (ACIP) recommends two prenatal vaccines: the influenza vaccine and the tetanus, diphtheria, pertussis (Tdap) vaccine.

Despite the importance of these vaccines in providing pregnant people and newborns with antibodies against infectious diseases, uptake of prenatal vaccines remains low. Vaccination rates are lower among people with Medicaid and CHIP than those with private health insurance, perhaps reflecting access disparities and low reimbursement rates.

The Manatt Health white paper analyzed Medicaid and CHIP policies to determine how the programs cover and reimburse for prenatal vaccines.

Most coverage pathways for pregnant people in Medicaid and CHIP include coverage for all ACIP-recommended vaccines, including prenatal vaccines. However, for adults 21 or older who qualify for Medicaid’s pregnancy-based coverage pathway, states can decide which prenatal vaccines to cover. Medicaid managed care organizations must cover the same benefits that fee-for-service Medicaid covers, though they can offer additional benefits.

Among states that do not expressly guarantee coverage for all ACIP-recommended vaccines through this pathway, Florida does not cover the influenza or Tdap vaccine; Virginia covers influenza, but not Tdap; Rhode Island covers Tdap, but not influenza; and Nebraska likely covers both as vaccines are covered on a case-by-case basis for medical necessity.

When the Inflation Reduction Act takes effect in October 2023, Medicaid and CHIP programs in all states must cover all ACIP-recommended vaccines.

While vaccine coverage can help facilitate access, it does not ensure it. Reimbursement standards also play a role in vaccine access.

Providers must incur supply costs, costs to store the vaccine, and administration costs when offering vaccinations.

Researchers found that most states reimburse physicians for vaccines at rates below those under Medicare Part B, which paid physicians $30 for administering influenza, pneumococcal, and hepatitis B and $16.96 for vaccines like tetanus and rabies in 2022.

For adults 21 and older, 41 states pay an administration fee. The average rate in 2022 was $10.54, or 33 percent of the Medicare Part B rate for administering the influenza vaccine. Twelve of the states pay an administration fee of $15 or more, while 20 states pay an administration fee of less than $10.

Most states reimburse physicians, nurse practitioners, physician assistants, and certified nurse midwives for vaccine administration at the same rate. States typically reimburse pharmacists at the same rate or higher for vaccine administration. Meanwhile, less than one out of three states pay federally qualified health centers (FQHCs) for vaccinations separate from the fixed rate for each medical visit.

State lawmakers can help increase access to prenatal vaccines for Medicaid and CHIP beneficiaries in several ways, the white paper shared.

First, states should establish adequate provider reimbursement standards for prenatal vaccines. This includes ensuring that reimbursement is available for vaccine administration during a billable office visit and matching Medicare Part B’s administration fee. Additionally, states should implement pricing benchmarks to ensure providers are not losing money on vaccine supply.

Second, policymakers should improve the Vaccines for Children (VFC) program, which furnishes vaccine supplies for free to participating providers for administering to beneficiaries under age 19. Specifically, states should expand program eligibility to include more providers and cover prenatal vaccines administered by OB/GYNs outside the VFC program, even if they usually exclude coverage for non-VFC vaccines.

Finally, states with managed care organizations should require them to cover prenatal vaccines administered by all provider types in all settings covered under fee-for-service Medicaid and direct them to reimburse for vaccine administration and supply at or above the state’s fee-for-service rates.

In addition, states should require managed care organizations to publish vaccine administration and supply reimbursement rates to support transparency.