Medical Expenditure Panel Survey (Selden et al., 1999). In some states, Medicaid enrollment has increased as a result of SCHIP outreach efforts (HCFA, 1999a). Finally, 23 states offer 12-month continuous eligibility in their separate SCHIP programs, as do 15 states for Medicaid (HCFA, 1999a). This longer minimum eligibility period should improve the continuity of primary care, including immunizations, received by enrolled children. Table 3–5 summarizes federal coverage policies for children under Medicaid, VFC, and SCHIP.

Enrollment in Medicaid in particular remains below the potential reach of the program, however, with 22 percent of all eligible children (4.7 million out of 21.2 million) not enrolled (Selden et al., 1998). This underenrollment appears to be the result of many factors, ranging from a lack of awareness of programs on the part of families to systemic barriers that make enrollment difficult (Ellwood, 1999).

Managed Care and Medicaid, VFC, and SCHIP

In 1998, all but four states mandated enrollment in managed care by some or all Medicaid beneficiaries as a condition of coverage for at least a portion of Medicaid benefits (information provided by HCFA). As of 1998, 16.6 million Medicaid enrollees (54 percent of the total), were enrolled in some form of managed care arrangement, a more than three-fold increase in Medicaid managed care enrollment since just 1993 (information provided by HCFA).

Freestanding SCHIP programs often involve managed care arrangements, with providers or provider groups, such as independent practice associations, being “at risk” for the services used by their enrollees. Because children enrolled in freestanding SCHIP programs are “insured” and therefore not eligible for VFC vaccines, the capitation rates paid to SCHIP plans ostensibly cover both the cost of purchasing required vaccines and the cost of administering them, unless the state makes other arrangements (see Box 3–2). In California, a state with a combination SCHIP program, some providers argue that the capitation rates in the freestanding SCHIP plans are set too low to compensate them for vaccine purchases, and some capitated providers have referred patients to public health clinics to receive free vaccinations (Fairbrother et al., forthcoming).

States that require beneficiaries to enroll in a managed care plan may require these plans to provide additional benefits and services not normally offered to Medicaid beneficiaries receiving care in the fee-for-service system.20 Thus even if immunizations were not otherwise covered for adults, a state Medicaid agency could specify such coverage in its managed care service agreements.

Very limited information is available on the extent of adult immuni-



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