19 States Must Align Medicaid Vaccine Coverage Policies with IRA

Almost two-fifths of US states—particularly those that have avoided Medicaid expansion—will need to change their Medicaid vaccine coverage policies in order to align with the Inflation Reduction Act, an Avalere white paper found.

The Inflation Reduction Act passed through Congress and received the presidential signature on August 16, 2022.

The law requires states to cover all recommended vaccines for adult Medicaid enrollees with zero cost-sharing by the beginning of October 2023. Coverage will be similar to commercial market requirements.

Avalere examined the difference between vaccine coverage pre-implementation of the Inflation Reduction Act and post-implementation. The white paper received funding but no editorial input from Pfizer.

The researchers used publicly available data to observe changes for five recommended vaccines: influenza, tetanus/diptheria/acellular pertussis (Tdap), human papillomavirus (HPV), pneumococcal polysaccharide vaccine (PPSV23), and pneumococcal conjugate vaccine (PCV13). Avalere conducted this research from April through December 2021.

There were 11 fee-for-service programs and 6 Medicaid managed care plans that did not cover at least one of the recommended vaccines. The researchers noted that states that did not adopt Medicaid expansion were more likely not to cover one or more of the recommended vaccines.

States were most likely not to cover vaccines that involved risk-based or shared clinical decision-making. Across the states that had coverage gaps, eight fee-for-service and Medicaid managed care plans did not cover the HPV vaccine. Six plans—five fee-for-service programs and one Medicaid managed care plan—did not cover the PCV13 vaccine. Every plan covered the influenza vaccine.

Additionally, five fee-for-service programs and one Medicaid managed care plan covered a vaccine but required cost-sharing, which could range from $0.65 to $4.00.

These findings are critical for the 19 states that need to adjust their Medicaid coverage policies or review Medicaid managed care plans’ coverage to align with the Inflation Reduction Act.

“Although IRA requirements will not take effect until October 1, 2023, states that do not already cover all ACIP-recommended vaccines without cost sharing for their full adult Medicaid populations will need to act quickly and modify coverage policies in the coming months to meet the IRA timeline,” Avalere researchers noted.

Avalere anticipated that CMS would offer guidance to help Medicaid programs and stakeholders understand their obligations.

The researchers warned that the law could be pursued in a way that increases care disparities. The Inflation Reduction Act did not fix low provider reimbursement rates for vaccinations that disincentivize this form of preventive care, and the law may not reimburse pharmacists and set up billing barriers.

“These barriers may also extend to safety net providers which disproportionally serve vulnerable individuals and families, like Federally Qualified Health Centers. These barriers could lead to increased health disparities for patients. Some Medicaid-related vaccine topics are likely to be addressed in forthcoming implementation guidance; interested stakeholders should consider whether and how to engage CMS to shape that guidance,” Avalere recommended.

During the coronavirus pandemic, health equity in coronavirus vaccine distribution was a critical issue, but the challenges proved to have a presence beyond the coronavirus vaccine as well.