VFC Eligibility

A: Health insurance is subject to the Employee Retirement Income Security Act of 1974 (ERISA) or is regulated by a state’s Insurance Commissioner as insurance. ERISA is a federal law that sets minimum standards for most voluntarily established pension and health plans in private industry to provide protection for individuals in these plans. Contact the state Insurance Commissioner to determine if an organization is a health insurance company.

A: Health insurance is defined as a plan subject to ERISA or regulated by the state’s Insurance Commissioner as insurance (see Q&A above). If the service does not fall in either of these two categories, the service is not considered a form of insurance for the purposes of the VFC program.

A: Individuals covered by medical savings accounts or health savings accounts must also have high deductible health plan coverage. Therefore, such individuals are insured.

A: If the child has no health insurance on the day he/she presents at the office for immunizations, the child would be VFC eligible because he/she is uninsured. VFC eligibility screening must take place with each visit even though the patient screening form needs to be updated only when the eligibility status of the child changes.

A: If the child has no health insurance on the day he/she presents at the office for immunizations, regardless of the reason, the child would be VFC eligible because he/she is uninsured.

A: VFC does not have a category specifically for the underserved. The term "underserved" refers to a geographic location such as a county or a census tract or a population living in a specific geographic location that has been designated by HRSA as medically underserved. For further information on medically underserved areas or population, please visit the Health Resources and Services Administration (HRSA) website.

It is common for VFC- eligible children to live in medically underserved areas or to be members of medically underserved populations.

A: Title V is not a type of health insurance so it has no effect on VFC eligibility of a child. To be eligible for VFC a child has to meet the age and eligibility criteria of the VFC program. Learn more about the Title V program on the HRSA website.

A: No. Children are eligible to participate in the VFC program only through age 18 years regardless of the child’s immunization status (series completed or series not completed) when they age out of VFC.

A: Yes, all children from birth through 18 years of age who are covered by Medicaid are considered VFC eligible because of their Medicaid status.

A: Yes, all children who have Medicaid as a secondary insurance are covered by VFC. The state Medicaid agency will pay the claim for the administration fee and seek reimbursement from the primary insurance.

A: Generally, providers are required to bill third parties before Medicaid will make payment (we refer to this as cost avoidance). However, there are a few exceptions to the cost avoidance rules. In the case of preventive pediatric services including EPSDT, if the Medicaid agency is billed, it is required to make payment and then seek reimbursement from the third party (CMS refers to this as pay & chase) - see 1902(a)(25)(E) of the Social Security Act. The Medicaid agency is to seek recovery as long as it is cost effective to do so, i.e., where the amount of reimbursement the State can reasonably expect to recover exceeds the cost of recovery (see 1902(a)(25)(B)). Since child immunizations fall under this exception, the provider has several options for billing the administration fee:

The provider could administer VFC vaccine, and then bill the maximum regional charge for the vaccine administration to the Medicaid agency and Medicaid would be responsible for seeking reimbursement from the primary insurance.

The provider could administer private stock vaccine and bill the primary insurance the usual and customary charge for both the vaccine and the vaccine administration fee.

If the primary insurance is billed first and the insurance denies the claim, the provider could replace the private stock vaccine used with VFC vaccine then bill the maximum regional charge for the vaccine administration fee to Medicaid. The Medicaid agency should bypass their cost avoidance edit allowing the claim to be considered for payment.

Also, if the third party payer pays less than the Medicaid amount for the vaccine administration fee, the provider can bill Medicaid for the balance of the vaccine administration fee up to the amount Medicaid pays for the administration fee.