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Calling the Shots: Immunization Finance Policies and Practices
diphtheria-tetanus-pertussis (DTP); Haemophilus influenza type b (Hib) conjugate; hepatitis B; measles, mumps, and rubella (MMR); oral poliovirus (OPV); and varicella. However, coverage was more variable for other pediatric vaccines.7 Respondents did not indicate whether their coverage was consistent with ACIP standards, nor did they report their cost-sharing policies.
The five companies reported more limited coverage of immunizations for adults. Three reported typical coverage of rubella vaccine for persons aged 25–65, two reported coverage of varicella for working-age adults, and three reported coverage of tetanus and diphtheria toxoids. Three companies reported covering influenza and pneumoccocal vaccines for enrollees over age 65, but not for younger adults.
Capitated managed care plans may realize savings from immunizing elderly and at-risk younger adults for influenza and pneumococcal disease, and are more likely than traditional indemnity insurance plans to cover and actively promote these immunizations. However, no systematic surveys of the extent of such coverage have been conducted.
Finding 3–1. While most private health plans provide some form of immunization coverage, this coverage varies by type of plan, as well as by vaccine. Enrollment in a private plan does not guarantee that immunizations will be provided as a plan benefit.
MEDICAID, VACCINES FOR CHILDREN, AND STATE CHILDREN’S HEALTH INSURANCE PROGRAM
Medicaid and Early and Periodic Screening, Diagnosis, and Treatment Program
Medicaid, the nation’s largest public insurance program for low-income and medically indigent persons, covered an estimated 31 million people in 1998, more than half of whom were children (Health Care Financing Administration, 2000c, 2000d). An additional estimated 4.7 million children aged 18 or younger who lacked health insurance and were eligible for Medicaid were not enrolled in it (Selden et al., 1998).
In 1967, 2 years after its inception, Medicaid was expanded to include comprehensive primary health care for children under age 21 through the Early and Periodic Screening, Diagnosis, and Treatment Program (EPSDT).8 Since then, Medicaid has been a significant source of funding (federal and state) for immunizations, and since 1979, immunizations have been a mandatory service for eligible children. Amendments to the Medicaid law in 1989 specifically codified immunizations as a mandatory component of the Medicaid program for individuals under age 21 and