Medicaid Vaccinations For Non-Institutionalized

Transcription

1 Medicaid Vaccinatins Fr Nn-Institutinalized 2013 Adult Enrllees BENEFIT DESIGN and COST-SHARING POLICY Alexandra M. Stewart, JD Kristen H.M. Chang, MPA Marisa A. Cx, M.A., MPH Immunizatin Law and Plicy Prgram (ILPP) Department f Health Plicy Schl f Public Health and Health Services The Gerge Washingtn University

2 This study updates ur 2003 reprt entitled Medicaid Cverage f Immunizatins fr Nn- Institutinalized Adults. 1 This is the first updated Medicaid issue brief, which examines vaccinatin benefits cverage and cst-sharing plicy. Future reprts in this series will examine reimbursement plicy and prgram management. This update was funded by the Natinal Center fr Immunizatin & Respiratry Diseases Immunizatin Services Divisin (NCIRD) f the Centers fr Disease Cntrl and Preventin (CDC) under Cntract Number The research was cmpleted between Octber 2011 and September Leightn Ku, Ph.D, MPH, Prfessr and Directr f the Center fr Health Plicy Research, Department f Health Services, Schl f Public Health and Health Plicy, The Gerge Washingtn University, prvided technical assistance related t develpment f the survey. Ricard Lpez, M.A., MPH, Research Assistant, Department f Health Plicy, Schl f Public Health and Health Services, The Gerge Washingtn University, prvided research supprt. The authrs thank the Medicaid prgram administratrs wh, despite limited resurces and busy schedules, supprted this prject by cmpleting the survey and prviding their expertise. Disclaimer: The findings and cnclusins in this reprt are thse f the authrs and d nt necessarily represent the fficial psitin f the Centers fr Disease Cntrl and Preventin. Suggested Citatin: Alexandra M. Stewart, Kristen H.M. Chang, Marisa A. Cx; Medicaid Vaccinatins fr Nn- Institutinalized Adult Enrllees: Benefit Design and Cst-sharing Plicy; Immunizatin Law and Plicy Prgram, Department f Health Plicy, Schl f Public Health and Health Services, The Gerge Washingtn University;

3 TABLE OF CONTENTS REPORT SUMMARY...4 INTRODUCTION...5 STUDY METHODOLOGY...5 BACKGROUND: BENEFIT COVERAGE DESIGN...6 Federal Requirements related t Cverage f Recmmended Vaccines fr Adults...7 RESEARCH FINDINGS...7 Survey Respnse and Ppulatin...7 Permissible Changes under the Patient Prtectin and Affrdable Care Act (ACA)...7 Prgram Respnse COVERED VACCINATION SERVICES FOR ADULTS...8 Cverage Decisins...9 Decisins t Cver Vaccines...9 Decisins nt t Cver Vaccines...10 Cverage Cmparisn: 2003 v TABLE 1: Medicaid Cverage f Adult Vaccines by CPT Cdes...13 TABLE 2: Medicaid Cverage f Vaccines fr Adult Enrllees, 2003 v BACKGROUND: COST-SHARING POLICY COST-SHARING FOR ADULT VACCINATION SERVICES...16 Permitting Cpayments fr Vaccinatin Services...16 Prhibiting Cpayments fr Vaccinatin Services...16 Cst-Sharing Cmparisn: 2003 v TABLE 3: Medicaid Cst-Sharing fr Adult Vaccinatin Services, 2003 v RESEARCH FINDINGS...19 The Affrdable Care Act, Benefit Design, and Cst-Sharing Plicy...19 CONCLUSION...20 APPENDIX...24 APPENDIX 1: Influential Factrs in Cverage Design Decisins...24 APPENDIX 2: 2012 Vaccine Cverage: Individual Vaccines

4 REPORT SUMMARY Federal Medicaid rules permit each state prgram t determine which adult vaccines, if any, will be cvered, the cst-sharing plicy fr adult vaccinatin services, prvider reimbursement plicy, and the settings where vaccines may be administered. These plicy decisins may impact bth the persnal health status f the enrllee and the public s health. Prgrams cvering all recmmended vaccines and prhibiting cst-sharing fr vaccinatin services supprt natinal public health gals fr adult vaccinatin. We fund that 17/51 prgrams cver all ACIP-recmmended vaccines and prhibit cst-sharing. Benefit Design: Ninety-eight percent f all prgrams (50/51) cver at least 1 vaccine fr nninstitutinalized adult enrllees, an increase frm 2003 when 94% f prgrams (47/50) cvered at least 1 vaccine. Mst prgrams (70.6%) cver all ACIP recmmended vaccines (36/51), representing a 6.6 percentage-pint increase frm 2003, when 32/50 prgrams cvered all recmmended vaccines. In 2003, Alaska, Flrida, and Luisiana did nt cver any vaccines; data was nt available fr Washingtn DC. By 2012, Alaska and Luisiana added cverage fr certain vaccines, while Flrida cntinues t exclude cverage f vaccines fr nn-institutinalized adults in Fur prgrams (Gergia, Nrth Dakta, Suth Dakta, Texas) decreased cverage since 2003, with Gergia eliminating the largest number f vaccines. In 2012, influenza vaccine was the mst frequently cvered vaccine (98%) (50/51). The least frequently cvered vaccine was zster, with 78% f prgrams cvering the vaccine (40/51). Factrs Influencing Benefit Design: The majrity f prgrams (31/42) ranked ACIP recmmendatins as the first r secnd mst influential factr in deciding t cver a vaccine. (Appendix 1) Prgrams als identified state health agency recmmendatins t the prgram (22/44), interest frm legislatrs and the gvernr (13/42), and public interest (3/42) as first r secnd mst influential factrs in cverage decisins. Prgrams cited csts assciated with cvering a vaccine (10/42) and lack f a state health agency recmmendatin t the prgram (9/42) as the mst influential factrs when cnsidering vaccines t exclude frm Medicaid cverage. Other factrs ranked first r secnd include the desire fr mre lngterm data (6/42), lw demand r interest frm state and lcal health prfessinals (5/42), and insufficient demand r interest frm state legislatrs r gvernrs (3/42). Cpayment Plicy: In 2003, 23/50 prgrams permitted and 27/50 prgrams did nt address cpayments, while n prgram prhibited cpayments (DC data unavailable). By 2012, 2 additinal prgrams permitted cpayments (25/51), and 21/51 prgrams prhibited the practice. Five prgrams did nt address cst-sharing fr vaccinatins. Seventeen prgrams that cver all recmmended vaccines als prhibit cpayments. Cpayments in 2003 ranged frm $0.50 t $3.00. By 2012, cpayments ranged frm $.50 t $3.40 r 5% f the allwable amunt the prgram permits a prvider t bill. The median and mde f maximum cpayments were $3.00 in bth 2003 and The Patient Prtectin and Affrdable Care Act (ACA) : Benefit Cverage and Cst-Sharing Decisins: Under the ACA, beginning January 1, 2014, prgrams that elect t cver all adult vaccines recmmended by ACIP and their administratin csts while prhibiting cst-sharing will receive an additinal 1% Federal Medical Assistance Percentages (FMAP). The majrity f prgram administratrs wh respnded t ur survey (n=42) indicated that their prgrams will nt alter cverage plicy fr previusly eligible adults (30/42). Fewer prgrams (11/42) are unclear abut hw their prgrams will respnd. Only Arkansas intends t increase vaccinatin cverage benefits fr previusly eligible adults t ensure the same benefit cverage as newly-eligible adults. N prgram reprted the intent t decrease vaccinatin cverage benefits fr previusly eligible adults. 4

5 INTRODUCTION The purpse f ur study was t cnduct a cmprehensive review f Medicaid prgrams apprach t vaccinatin benefits fr nn-institutinalized adult enrllees. This review supprts effrts t understand hw Medicaid prgrams respnd t changes in the regulatry and fiscal envirnment, and hw these changes impact access t recmmended vaccinatins fr adult enrllees. We assessed prgrams plicies related t vaccinatin benefits cverage, cst-sharing, and anticipated respnse t health refrm in the 50 states and the District f Clumbia. STUDY METHODOLOGY In rder t cmplete the study, we: A. Cnducted a dcument review: Beginning Octber 2011, we identified and reviewed all publicly available material relating t benefit cverage, cst-sharing, and payment fr adult vaccinatin under Medicaid frm all 50 states and the District f Clumbia. The review included state-issued prvider manuals, physician bulletins and newsletters, cnsumer handbks, fee schedules, legislatin, and cmmercially available state plan summaries related t cverage f, cst-sharing fr, and payment fr adult vaccinatin services under Medicaid. B. Identified relevant CPT cdes t determine cverage practices: Current Prcedural Terminlgy (CPT) cdes are used by healthcare cnsumers and prviders t represent individual vaccine frmulatins. In the 2003 study, nly ne pre-selected CPT cde per vaccine was used as a measure f benefit cverage, and may have resulted in an underestimatin f cverage. The 2012 study incrprates all CPT cdes applicable t each vaccine under review t ensure accurate measurement f vaccine benefit cverage. (Appendix 2) C. Develped, deplyed, and analyzed a survey fr each Medicaid prgram: We drafted a survey t btain infrmatin related t adult vaccinatin frm each Medicaid prgram that was nt readily available thrugh the dcument review. 2 3 D. Identified the elements f a cmprehensive adult vaccinatin prgram: Each prgram s plicies and practices were reviewed against a list f five elements develped fr this prject. These elements cnsist f the cre practices that we believe will prmte increased access t recmmended vaccinatins fr Medicaid enrllees ages 19 thrugh 64, including: 1. Whether the prgram cvers all eleven vaccines recmmended fr adults by ACIP in Whether the prgram prhibits cst-sharing fr adult vaccinatin services 3. Whether the prgram permits reimbursement f vaccines and their administratin prvided t adult enrllees 5

6 4. Whether the prgram permits reimbursement f vaccinatin services fr adults administered by a wide range f prviders 5. Whether the prgram permits reimbursement f adult vaccinatin services administered in a wide range f settings This brief addresses the first and secnd elements (cverage and cst-sharing), data btained thrugh the dcument review and survey. The remaining elements will be discussed in future reprts in this series. E. Dcumented, analyzed, and cmpared the research results: Results f the review were charted and analyzed fr each prgram and cmpared t data frm The Epidemilgy f US Immunizatin Law: Medicaid Cverage f Immunizatins fr Nn- Institutinalized Adults (2003 study) that includes results frm 47/50 prgrams (94%). 4 BACKGROUND: BENEFITS COVERAGE DESIGN Medicaid is the largest surce f funding fr medical and health-related services fr America s prest peple, wh generally d nt have access t r cannt affrd emplyer-based r individual insurance in the private market Every U.S. state, the District f Clumbia, and five Territries perate prgrams In 2011, ver 19 millin adults age 19 thrugh 64 were enrlled, with almst 11 millin residing in ten states (Califrnia, New Yrk, Flrida, Pennsylvania, Michigan, Ohi, Illinis, Texas, Massachusetts, and Tennessee) The prprtin f adult enrllees varies by state, ranging frm 4% in New Hampshire t 19% in the District f Clumbia and Vermnt in The Cngressinal Budget Office estimates that the ttal number f adults enrlled in Medicaid will increase t 31 millin in 2017 as a result f the Affrdable Care Act. 14 Medicaid enrllees have greater health care needs and higher health risks than privately insured individuals in the US They have few assets and ften cannt affrd t purchase medical insurance in the private market. Additinally, Medicaid enrllees experience disprprtinately lw rates f preventive care and are typically unable t affrd t purchase vaccinatin services ut-f-pcket due t the relatively high cst f vaccines in relatin t their persnal incme. 20 Withut Medicaid cverage, lw incme adults wuld necessarily rely n public health agencies, cmmunity health centers, and ther public clinics fr subsidized vaccinatins. Funds available t public health agencies under the 317 prgram are limited in relatin t the ttal number f institutinalized and nn-institutinalized lw incme adults wh need free vaccines. Medicaid plicy related t vaccinatins fr adult enrllees may directly impact bth the persnal health status f the enrllee and the public s health. Prgrams that cver all ACIP recmmended vaccines wuld supprt the Healthy Peple 2020 gals related t seasnal flu, pneumcccal, hepatitis B, and zster vaccinatins fr adults, since health insurance cverage is assciated with higher vaccinatin rates amng adults. 6

7 Because the impsitin f even small cpayments has been shwn t impair access t care fr pr individuals, prgrams that eliminate cpayments culd significantly increase access t vaccinatins fr enrllees. Therefre, prgrams that prhibit any frm f cst-sharing fr vaccinatin services als supprt natinal public health gals by remving significant financial barriers fr this ppulatin. Federal Requirements related t Cverage f Recmmended Vaccines fr Adults Under federal Medicaid rules, prgrams are nt required t prvide any vaccinatin services t traditinally eligible adult enrllees, thse wh were eligible fr Medicaid prir t January 1, As a result, vaccinatin services fr adult enrllees are gverned at the prgram level: each prgram determines which adult vaccines, if any, will be cvered, the cstsharing plicy fr enrllees, prvider reimbursement plicies, and the settings where cvered vaccines may be administered. This flexibility results in distinct prgrams acrss each jurisdictin. RESEARCH FINDINGS Survey Respnse and Ppulatin After distributing the survey t all 50 states and DC, 42 prgrams (82.4%) respnded. Seven prgrams did nt respnd, and tw declined t participate (Illinis, Kansas, New Hampshire, Nrth Carlina, Ohi, Pennsylvania, Rhde Island, West Virginia, and Wiscnsin). The 42 respndents cver apprximately 16 millin f the mre than 19 millin Medicaid enrllees ages 19 thrugh The median respndent prgram has apprximately 223,210 enrllees in this age grup. Respndents included 6 f the 10 largest prgrams (Califrnia, New Yrk, Texas, Flrida, Massachusetts, Michigan), cvering 41% f all enrllees ages 19 thrugh 64. Permissible Changes under the Patient Prtectin and Affrdable Care Act (ACA) The Patient Prtectin and Affrdable Care Act (ACA), 29 as interpreted by the Supreme Curt in Natinal Federatin f Independent Business v. Sebelius, permits prgrams t expand eligibility fr all persns with family incmes under 133 percent f the Federal Pverty Level (FPL) Effective January 1, 2014, prgrams that chse t implement this change are required t extend benchmark cverage t the newly eligible enrllees. Benchmark cverage is expected t include cverage f vaccinatins fr adults. 34 As a result, beneficiaries wh enrll in Medicaid n r after January 1, 2014, will have ensured access t ACIP recmmended vaccines. Hwever, vaccinatin services will remain ptinal fr adult enrllees wh qualify thrugh traditinal eligibility categries. Under the ACA, beginning January 1, 2014, prgrams that elect t cver all adult vaccines recmmended by the Advisry Cmmittee n Immunizatin Practices (ACIP) f the Centers fr Disease Cntrl and Preventin (CDC) and their administratin csts while prhibiting cst-sharing will receive an additinal 1% Federal Medical Assistance Percentages (FMAP). 35 The FMAP determines the amunt f federal matching funds that prgrams receive fr expenditures related t certain scial services including Medicaid. 36 Based 7

8 n Sectin 1905(b) f the Scial Security Act, the FMAP can range frm 50.0 t 83.0%. 37 fiscal year 2012, FMAP ranged frm 50.0% t 74.2%. Fr Prgram Respnses Medicaid administratrs were asked whether changes impsed under health refrm will impact their prgrams vaccine cverage plicy fr traditinally eligible adults wh enrlled befre January 1, 2014 (Survey questin 3, n=42). Prgrams were prvided 4 ptins t respnd: 1) will increase cverage f vaccines fr previusly eligible adults, 2) will nt change cverage plicy, 3) will decrease cverage, and 4) unclear n hw the prgram will prceed. The 42 respnses are listed belw: 1/42 prgrams (Arkansas) indicated they will increase cverage f vaccines fr previusly eligible adults t ensure the same cverage level as newly-eligible adults. Enrllees will gain access t varicella, HPV, and zster vaccines because the prgram did nt cver thse vaccines in /42 prgrams indicated that they will decrease cverage f vaccines fr previusly eligible adults. 30/42 prgrams indicated that they will nt change vaccine cverage plicy fr previusly eligible adults. 23/30 prgrams cvered all recmmended vaccines in 2012, resulting in the same cverage fr the different categries f adult Medicaid enrllees (Alaska, Califrnia, Cnnecticut, Delaware, Hawaii, Idah, Iwa, Maryland, Massachusetts, Michigan, Minnesta, Missuri, Nevada, New Jersey, New Mexic, New Yrk, Oklahma, Oregn, Tennessee, Utah, Vermnt, Virginia, Wyming). 7/30 prgrams did nt cver all recmmended vaccines in Thus, beginning January 1, 2014, these prgrams will be required t manage dual benefit packages fr adult Medicaid enrllees (Alabama, District f Clumbia, Flrida, Luisiana, Mississippi, Nrth Dakta, Texas). Texas nted that they may add benefit cverage fr zster and enhanced immungenicity influenza vaccines. Hwever, the prgram has determined that it will nt add cverage fr meningcccal r varicella vaccines. 11/42 prgrams indicated that they are unclear abut hw they will manage vaccine cverage plicy fr the different categries f enrllees. 5/11 prgrams cvered all recmmended vaccines in 2012 (Indiana, Kentucky, Maine, Mntana, Nebraska). 6/11 prgrams did nt cver all recmmended vaccines in Administratrs in Arizna and Gergia reprt they are unclear abut the budgetary impact f plicy changes. Cverage plicy changes are under review in Suth Carlina. Clrad, Suth Dakta and Washingtn did nt ffer additinal cmments COVERED VACCINATION SERVICES FOR ADULTS (TABLE 1,2) In 2012, the ACIP recmmends 11 vaccines fr rutine r catch-up use amng adults wh are members f the civilian ppulatin. 38 The vaccines are: 1) hepatitis A, 2) influenza, 3) measles mumps and rubella (MMR), 4) varicella, 5) tetanus, diphtheria (Td), 6) tetanus diphtheria and acellular pertussis (Tdap), 7) pneumcccal, 8) meningcccal, 9) hepatitis B, 10) human papillmavirus (HPV), and 11) zster (shingles). Table 1 and Appendix 2 shw vaccine cverage plicy amng the 51 Medicaid prgrams as determined by the dcument review and verified by the survey (where available): 8

9 50/51 prgrams (98.0%) cvered at least ne adult vaccine in Flrida is the nly prgram t exclude vaccines frm its benefit package fr nn-institutinalized adult enrllees. 36/51 prgrams (70.6%) cvered all ACIP recmmended vaccines in Alaska, Califrnia, Cnnecticut, Delaware, Hawaii, Idah, Illinis, Indiana, Iwa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesta, Missuri, Mntana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexic, New Yrk, Nrth Carlina, Oklahma, Oregn, Pennsylvania, Rhde Island, Tennessee, Utah, Vermnt, Virginia, West Virginia, Wiscnsin, Wyming. 15/51 prgrams (29.4%) did nt cver all ACIP recmmended vaccines in Alabama, Arizna, Arkansas, Clrad, District f Clumbia, Flrida, Gergia, Luisiana, Mississippi, Nrth Dakta, Ohi, Suth Carlina, Suth Dakta, Texas, Washingtn. Luisiana and Mississippi cvered the fewest vaccines (4/11). COVERAGE DESIGN DECISIONS Decisins t Cver Vaccines Medicaid administratrs were asked t rank the factrs influencing their decisins t cver vaccines frm mst influential t least influential (1 st 5 th ) (survey questins 11-12, n=42). Factrs included: ACIP/CDC recmmendatins, state health agency, r state r lcal health prfessinal recmmendatin t the Medicaid prgram, interest frm legislatrs r the gvernr, and interest frm the public. Appendix 1 illustrates the 42 respnses: 31/42 prgrams cited ACIP recmmendatin as the 1 st r 2 nd mst influential factr in determining whether t cver a vaccine fr adult Medicaid enrllees. Alaska, Arizna, Arkansas, Califrnia, Clrad, Cnnecticut, Delaware, District f Clumbia, Gergia, Idah, Indiana, Iwa, Kentucky, Luisiana, Maine, Maryland, Massachusetts, Michigan, Minnesta, Mississippi, Mntana, Nevada, New Jersey, New Mexic, Oklahma, Tennessee, Texas, Utah, Vermnt, Washingtn, Wyming. 22/42 prgrams cited state health agency recmmendatin as the 1 st r 2 nd mst influential factr. Alabama, Alaska, Clrad, Delaware, District f Clumbia, Idah, Iwa, Kentucky, Massachusetts, Minnesta, Mississippi, Missuri, Mntana, Nevada, New Mexic, Nrth Dakta, Oklahma, Oregn, Suth Dakta, Texas, Vermnt, Wyming. 13/42 prgrams cited state/lcal health prfessinal recmmendatin as the 1 st r 2 nd mst influential factr. Arizna, Delaware, District f Clumbia, Luisiana, Maryland, Minnesta, Mississippi, Nebraska, Nrth Dakta, Oklahma, Suth Dakta, Washingtn, Wyming. 12/42 prgrams cited interest frm the legislatrs/gvernr as the 1 st r 2 nd mst influential factr. Alabama, Arkansas, Delaware, District f Clumbia, Gergia, Maine, Minnesta, Mississippi, Nebraska, Oklahma, Utah, Virginia. 9

10 3/42 prgrams cited interest frm the public as the 1 st r 2 nd mst influential factr. Delaware, Gergia, Oklahma. 3/42 prgrams cited ther reasns as the 1 st r 2 nd mst influential factrs. Indiana- 1 st factr is FDA apprval. Oregn- 1 st factr is OR Health Evidence Review Cmmissin recmmendatin. Tennessee- 2 nd factr is gd public plicy/return n investment. 3/42 prgrams cited factrs unknwn Flrida, Hawaii, Suth Carlina Decisins nt t Cver Vaccines Medicaid administratrs were asked t rank the factrs influencing their decisins nt t cver vaccines frm mst influential t least influential (1 st 6 th ) (survey questins 13-14, n=42). Factrs included: cst, n recmmendatin frm state health agency t the prgram, a desire fr mre lng-term data, and lack f demand r interest frm the public, state r lcal health prfessinals, r legislatrs r the gvernr. Of the 42 respnding prgrams, 19/42 indicated that they did nt rank factrs because they currently cver all recmmended vaccines (9/42 prgrams ranked factrs and indicated that they cver all recmmended vaccines). Therefre, the respnses belw reflect the 23 respnding prgrams which ranked factrs. Appendix 1 shws all the respnses: 10/23 prgrams cited cst as the 1 st r 2 nd mst influential factr. Arizna, Clrad, District f Clumbia, Flrida, Gergia, Luisiana, Mississippi, Nrth Dakta, Texas, Utah. 9/23 prgrams cited lack f a state health agency recmmendatin as the 1 st r 2 nd mst influential factr. Alaska, Gergia, Missuri, Mntana, Nrth Dakta, Suth Dakta, Texas, Vermnt, Washingtn. 6/23 prgrams cited desire fr mre lng-term data as the 1 st r 2 nd mst influential factr. Clrad, Mntana, Nebraska, Nevada, Vermnt, Washingtn. 5/23 prgrams cited lack f demand/interest frm state/lcal health prfessinals as the 1 st r 2 nd mst influential factr. Alaska, Arizna, Luisiana, Nevada, Suth Dakta. 3/23 prgrams cited lack f demand/interest frm legislatrs/gvernr as the 1 st r 2 nd mst influential factr. Missuri, Utah, Virginia. 0/23 prgrams cited lack f demand/interest frm the public as the 1 st r 2 nd mst influential factr. 2/23 prgrams cited ther reasns as the 1 st r 2 nd mst influential factr. Indiana: 1 st factr is n FDA apprval. Virginia: 2 nd factr is lack f medical necessity. 10

11 Cverage Cmparisn: 2003 v We cmpared hw prgrams cvered adult vaccinatin benefits in 2003 t ur 2012 results. Table 2 and Appendix 2 detail changes in prgrams cverage f individual vaccines. In general, prgrams included mre vaccines in their benefit packages in 2012 than in /50 prgrams (94.0%, DC data unavailable) cvered at least ne vaccine fr adults in Prgrams with cverage f at least ne vaccine increased 4.0 percentage-pints t 50/51 (98.0%) by /50 prgrams (64.0%) cvered all ACIP recmmended vaccines in Prgrams cvering all recmmended vaccines increased 6.6 percentage-pints t 36/51 (70.6%) by /51 prgrams (49.0%) cvered all ACIP recmmended vaccines in bth 2003 and Prgrams cvering all ACIP recmmended vaccines in 2012 nly (36/51): Alaska, Califrnia, Cnnecticut, Delaware, Hawaii, Idah, Illinis, Indiana, Iwa, Kansas, Kentucky, Maine, Maryland, Massachusetts, Michigan, Minnesta, Missuri, Mntana, Nebraska, Nevada, New Hampshire, New Jersey, New Mexic, New Yrk, Nrth Carlina, Oklahma, Oregn, Pennsylvania, Rhde Island, Tennessee, Utah, Vermnt, Virginia, West Virginia, Wiscnsin, Wyming. Prgrams cvering all ACIP recmmended vaccines in 2003 and 2012 (25/51): Califrnia, Cnnecticut, Delaware, Hawaii, Idah, Illinis, Indiana, Iwa, Kansas, Maine, Maryland, Michigan, Minnesta, Mntana, Nebraska, Nevada, New Hampshire, New Mexic, New Yrk, Oregn, Pennsylvania, Vermnt, West Virginia, Wiscnsin, Wyming. Amng the 3/50 prgrams (6.0%) that did nt cver any vaccines in 2003: By 2012, Alaska and Luisiana added cverage f certain vaccines. Alaska nw cvers all recmmended vaccines. Luisiana cvers 4/11 vaccines (influenza, Td, pneumcccal, and HPV). Flrida cntinues t exclude all vaccines frm the adult benefit package. Only institutinalized adult enrllees are cvered fr influenza and pneumcccal vaccines. 4/51 prgrams (7.8%) decreased vaccine benefits since 2003 (Gergia, Nrth Dakta, Suth Dakta, Texas). Since 2003: Gergia n lnger cvers pneumcccal, TD, MMR, and varicella vaccines (added cverage f Tdap, HPV, and zster vaccines). Nrth Dakta n lnger cvers varicella vaccine (added cverage f Tdap vaccine). Suth Dakta n lnger cvers pneumcccal vaccine (added cverage f Tdap, hepatitis A, and zster vaccines). Texas n lnger cvers meningcccal and varicella vaccines (added cverage f Tdap and HPV vaccines). Changes in cverage f vaccines recmmended in bth 2003 and 2012 include (Table 2, Appendix 2): Influenza: 43/50 prgrams in 2003 t 50/51 in 2012 (12.0 percentage-pint increase). Pneumcccal: 47/50 prgrams in 2003 t 48/51 in 2012 (0.1 percentage-pint increase). Td: 40/50 prgrams in 2003 t 47/51 in 2012 (12.2 percentage-pint increase). Hepatitis A: 38/50 prgrams in 2003 t 47/51 in 2012 (16.2 percentage-pint increase). 11

12 Hepatitis B: 42/50 prgrams in 2003 t 49/51 in 2012 (12.1 percentage-pint increase). MMR: 42/50 prgrams in 2003 t 46/51 in 2012 (6.2 percentage-pint increase). Meningcccal: 39/50 prgrams in 2003 t 47/51 in 2012 (14.2 percentage-pint increase). Varicella: 40/50 prgrams in 2003 t 43/51 in 2012 (4.3 percentage-pint increase). Cverage f vaccines recmmended since 2003 include: Tdap: 46/51 prgrams. The vaccine was recmmended fr use in adults wh have nt already received the vaccine already, especially thse wh are in cntact with infants yunger than 12 mnths, in December HPV: 44/51 prgrams. The vaccine was recmmended fr use in adults ages 19 thrugh 26 in March Zster: 40/51 prgrams. The vaccine was recmmended fr use in adults ages 60 and lder in June

13 Xxx xxxxxx TABLE 1: MEDICAID COVERAGE f ADULT VACCINES by CPT CODES (n=51) FLU PNEUMO TD TDAP HEP A HEP AB HEP B MMR MENING HPV VAR ZOS PGM PROGRAM Alabama 1 2. Alaska 2 3. Arizna 3 4. Arkansas 4 5. Califrnia 5 6. Clrad 6 7. Cnnecticut 7 8. Delaware 8 9. District f Cl Flrida Gergia Hawaii Idah Illinis Indiana Iwa Kansas Kentucky Luisiana α Maine Maryland Massachusetts Michigan Minnesta Mississippi Missuri Mntana Nebraska Nevada α N. Hampshire N. Jersey N. Mexic N. Yrk N. Carlina N. Dakta Ohi Oklahma Oregn Pennsylvania R. Island S. Carlina β S. Dakta Tennessee Texas Utah Vermnt Virginia Washingtn W. Virginia Wiscnsin Wyming 51 TOTALS: 12/51 45/51 45/51 40/51 6/51 18/51 48/51 44/51 43/51 46/51 47/51 41/51 41/51 47/51 42/51 46/51 44/51 44/51 42/51 32/51 43/51 40/51 NOTES: Data as f 2012: dcument review. Flrida excluded: Des nt cver any vaccines fr nn-institutinalized adults. α N CPT cde specified. β S. Carlina uses Q fr (intramuscular influenza vaccine, age 3+). Bld= cvers all recmmended vaccines. Surce: GWU/SPHHS Medicaid Benefit Design and Cst-sharing Plicy

14 --ddd TABLE 2: MEDICAID COVERAGE f VACCINES fr ADULT ENROLLEES 2003 v (n= 51) Prgram Cvering all ACIP Recmmended Vaccines fr Adults in 2003 and 2012 (n=25) Califrnia Cnnecticut Delaware Hawaii Idah Illinis Indiana Iwa Kansas Maine Maryland Michigan Minnesta Mntana Nebraska Nevada New Hampshire New Mexic New Yrk Oregn Cverage f Vaccines fr Adults in 2003 (+), 2012 ( ), r Neither 2003/2012 (grey bx) Pennsylvania Vermnt West Virginia Wiscnsin Wyming PROGRAM FLU PNEUMO TD TDAP* HEP.A HEP.B MMR MENING HPV* VAR ZOS* Alabama Alaska Arizna Arkansas Clrad District f Cl. Flrida Gergia Kentucky Luisiana Massachusetts Mississippi + + Missuri N. Jersey N. Carlina N. Dakta Ohi Oklahma Rhde Island + + S. Carlina S. Dakta Tennessee Texas Utah Virginia + + Washingtn TOTALS: 43/50 47/50 40/50 * 38/50 42/50 42/50 39/50 * 40/50 * 2012 TOTALS: 50/51 48/51 47/51 46/51 47/51 49/51 46/51 47/51 44/51 43/51 40/51 Data as f 2012: dcument review (see methds). Flrida: Des nt cver any vaccines fr nn-institutinalized adults. DC: 2003 data unavailable. *N recmmendatin in Bld= cvers all recmmended vaccines in Surce: GWU/SPHHS Medicaid Benefit Design and Cst-sharing Plicy

15 BACKGROUND: COST-SHARING POLICY Prgrams are permitted t impse varius frms f cst-sharing fr mst Medicaid benefits including cpayments, cinsurance, deductibles, and ther charges. With sme exceptins, all Medicaid enrllees are subject t ut-f pcket csts. Hwever, prviders are required t treat an enrllee wh is unable t pay fr the service. They may als attempt t cllect unpaid fees. Our study addresses cst-sharing in the frm f cpayments. Cpayments fr mst services, including vaccinatins, are limited t nminal amunts depending n an enrllee s incme and health status, the categry f prvider, the service categry, and the setting in which the service is prvided. Generally, the maximum permissible cpayment is based n the amunt the prgram pays fr the service, and is updated annually t accunt fr the increasing cst f medical care (Figure 1). In mst cases, cpayments range frm $1.00 t $3.00. Enrllees with incmes abve 100% f the FPL may be required t pay higher cpayment amunts and alternative ut-f-pcket csts (Figure 2). These higher charges depend n the service, but cannt exceed 5% f family incme. Additinally, these enrllees with higher incmes may be denied services fr nnpayment f alternative cpayments. Certain enrllees are exempt frm ut f pcket csts, including: 1) individuals receiving hspice care; 2) American Indians and Alaska Natives wh have received services frm the Indian Health Service, tribal health prgrams, r under cntract health services referral; and 3) wmen enrlled in Medicaid under the Breast and Cervical Cancer Treatment Prgram (exempted frm alternative ut-f-pcket csts nly). 43 Adult enrllees seeking emergency, family planning, pregnancy-related services are als exempt frm ut-f-pcket csts. 44 Figure 1 FY 2012: Maximum Nminal Cpayment and Deductible, and Managed Care Cpayment 45 Maximum Nminal Cpayment $.65 fr services $10.00 r less Maximum Nminal Cpayment $1.30 fr services $10.01 t $25.00 Maximum Nminal Cpayment $2.55 fr services $25.01-$50.00 Maximum Nminal Cpayment $3.80 fr services $50.01 r mre Maximum Nminal Deductible $2.55 Managed Care Cpayment $3.80 Figure 2 FY 2012: Maximum Allwable Cpayment fr Eligible Ppulatins by Incme 46 <100% FPL % FPL >150% FPL Nn-Institutinal Care (physician visits, physical therapy, etc.) $ % f csts 20% f csts Nn-emergency use f the ER $3.80 $7.60 N limit 15

16 2012 COST-SHARING FOR ADULT VACCINATION SERVICES Permitting Cpayments fr Vaccinatin Services In 2012, data n cpayments was cllected frm 46 prgrams via dcument review. Cpayments fr adult vaccinatin services ranged frm $.50 t $3.40 r 5% f the allwable amunt the prgram permits a prvider t bill. The mean f maximum cpayments was $2.81, the median was $3.00, and the mde was $3.00. Medicaid cpayment requirements fr adult vaccinatins in 2012 are summarized belw (Table 3) /51 prgrams (47.1%) permitted cpayments (Alabama, Alaska, Arizna, Califrnia, Clrad, Flrida, Gergia, Indiana, Iwa, Luisiana, Maine, Michigan, Minnesta, Mississippi, Missuri, Mntana, Nebraska, New Yrk, Nrth Carlina, Nrth Dakta, Pennsylvania, Suth Carlina, Suth Dakta, Vermnt, Virginia). 1/25 prgrams permitted a maximum cpayment f $1.00 (Califrnia). 5/25 prgrams permitted a maximum cpayment f $2.00 (Flrida, Indiana, Michigan, Mntana, Nrth Dakta). 11/25 prgrams permitted a maximum cpayment f $3.00 (Alabama, Clrad, Gergia, Iwa, Maine, Mississippi, Missuri, Nebraska, New Yrk, Vermnt, Virginia). 1/25 prgrams permitted cpayment based n a scale frm $.50-$3.00 depending n the cst f services (Luisiana). 2/25 prgrams permitted a maximum cpayment f mre than $3.00 (Arizna- $3.40, Suth Carlina- $3.30). 2/25 prgrams permitted a maximum cpayment f $3.00 r up t 5% f the allwable amunt, the maximum amunt an insurer wuld cnsider reimbursing fr a cvered service (Alaska, Suth Dakta). 48 3/25 prgrams permitted cpayments but did nt publish the amunts required (Minnesta, Nrth Carlina, Pennsylvania). Prhibiting Cpayments fr Vaccinatin Services Prgrams prhibit cpayments fr adult vaccinatin services using abut 10 methds. Sme prgrams bar cpayments fr entire categries f medical services that culd incrprate vaccinatin, while ther prgrams decided t cnfine their prhibitin plicy t a specific service r circumstance. Fr example, these narrwly defined n cpayment plicies culd apply t the care setting, the service prvided, r the service prvider. The prgrams and methds f cpayment prhibitin are presented belw. 21/51 prgrams (41.2%) prhibited cpayments fr Medicaid vaccinatin services: physician, preventive, r vaccinatin alne. 8/21 prgrams prhibited cst-sharing fr Medicaid/physician services (District f Clumbia, Cnnecticut, Kansas, Maryland, Massachusetts, Nevada, Rhde Island, Washingtn). 4/21 prgrams prhibited cst-sharing fr all preventive care/services (Idah, Kentucky, New Mexic, Tennessee). 16

17 9/21 prgrams prhibited cst-sharing fr all vaccinatins/immunizatins/shts (Arkansas 49, Illinis, New Jersey, Ohi, Oklahma, Oregn, Utah, Wiscnsin, Wyming). 7/51 prgrams (13.7%) smetimes prhibited cpayments fr vaccinatins (under certain cnditins) Hwever, fr the purpses f this study, nly the prgrams that always prhibit cpayments fr vaccinatin services were included in the cpayment prhibitin categry. Gergia n cpayments fr physician and nurse practitiner visits. Luisiana n cpayments fr influenza vaccine administered by pharmacists. Minnesta n cpayments fr ffice visits. Nebraska n cpayments fr primary care services frm physicians r physician extenders. 52 New Yrk n cpayments fr private dctr s ffice visits. 53 Nrth Carlina n cpayments unless vaccine is prvided as a prescriptin. Pennsylvania n cpayments fr vaccine administered by a physician. Cpayments fr Vaccinatin Services were Nt Addressed (Silent) 5/51 prgrams (9.8%) did nt address their cpayment plicies. Delaware, Hawaii, New Hampshire, Texas, West Virginia. Cst-Sharing Cmparisn: 2003 v Prgrams permitting cpayments in 2003 had a mean f $2.30, a median f $3.00, and a mde f $3.00. Since 2003, n prgram has decreased its maximum cpayment and sme prgrams have increased the amunt required. Hwever, mst prgrams that impsed cstsharing requirements in 2003 have maintained the same requirements. The infrmatin belw summarizes changes since 2003 (Table 3). In general, mre prgrams addressed cpayment plicy fr vaccinatin services in 2012 than in /51 prgrams (45.1%) permitted cpayments in Prgrams permitting the practice increased 3.9 percentage-pints t 25/51 prgrams (49.0%) by /51 prgrams prhibited cpayments in Prgrams prhibiting the practice increased 41.2 percentagepints t 21/51 by /51 prgrams (45.1%) published cst-sharing plicies in This increased 45.1 percentage-pints t 46/51 prgrams (90.2%) by Amng prgrams permitting cst-sharing, maximum cpayment increased frm $0.50-$3.00 in 2003 t $0.50-$3.40 r 5% f the allwable amunt in 2012 (amng prgrams with data frm bth years). 4/25 prgrams increased their cpayments since 2003 (Arizna, Mississippi, Missuri, Suth Dakta). 10/25 prgrams kept the same cpayments since 2003 (Alabama, Califrnia, Clrad, Flrida, Gergia, Mntana, Nebraska, Nrth Dakta, Vermnt, Virginia). 17

18 Sharing: (Table XXX) TABLE 3: MEDICAID COST-SHARING fr ADULT VACCINATION SERVICES, 2012 (n=51) 2003 Cst-Sharing 2012 Cst-Sharing PROGRAM Permit Prhibit Nt Addressed Permit Prhibit Nt Addressed Alabama A C A C Alaska C F Arizna A D Arkansas Califrnia A A Clrad B C B C Cnnecticut Delaware Dist. f Cl. DC: 2003 data unavailable. Flrida B B Gergia B C C H Hawaii Idah Illinis A Indiana B Iwa C Kansas A E Kentucky Luisiana E Maine C Maryland Massachusetts Michigan B Minnesta H Mississippi A B C Missuri A B A C Mntana A B A B Nebraska B C B C Nevada N. Hampshire N. Jersey N. Mexic N. Yrk C H N. Carlina C I N. Dakta B B Ohi Oklahma A C Oregn C Pennsylvania E Rhde Island S. Carlina C D S. Dakta B C F Tennessee Texas Utah Vermnt C C Virginia A C A C Washingtn West Virginia Wiscnsin A B C Wyming B TOTAL: 23/50 0/50 27/50 25/51 21/51 5/51 Data as f A - E Cpayment fr physician r utpatient hspital services= A $1.00; B $2.00; C $3.00; D $3.00+; E Scaled cst-sharing ($.50 fr services <$10, $1 fr s<$25, $2 fr s <$50, $3 fr s<$50+); F %5 allwable amt. H N cpayment fr ffice visits nly. I N cpayment unless immunizatin is a prescriptin. Bld= cvers all recmmended vaccines in Surce: GWU/SPHHS Medicaid s Cverage and Cst-sharing fr Adult Vaccines

19 RESEARCH FINDINGS The Affrdable Care Act, Benefit Design, and Cst-Sharing Plicy Medicaid administratrs were asked t estimate the impact f ACA changes n benefit design and cst-sharing plicies (survey questin 2). Beginning January 1, 2014, prgrams cvering all recmmended adult vaccines and prhibiting cst-sharing will receive a 1% increase in the Federal Medical Assistance Percentage (FMAP). Calculated annually, the FMAP determines the federal cntributin each prgram is eligible t receive t supprt Medicaid. Frty-tw prgrams respnded t this survey questin. 25/42 prgrams indicated that the prvisin will have n impact n cverage and cst-sharing. 11/25 prgrams cvered all recmmended vaccines and prhibited cst-sharing (Cnnecticut, Idah, Maryland, Massachusetts, Nevada, New Jersey, New Mexic, Oklahma, Tennessee, Utah, Wyming). 7/25 prgrams cvered all recmmended vaccines and permitted cst-sharing (Indiana, Iwa, Michigan, Minnesta, Missuri, Oregn, Virginia). 1/25 prgrams cvered all recmmended vaccines and cst-sharing was unknwn (Hawaii). 4/25 prgrams did nt cver all recmmended vaccines and prhibited cst-sharing (Arkansas, District f Clumbia, Flrida, Washingtn). 2/25 prgrams did nt cver all recmmended vaccines and permitted cst-sharing (Arizna, Suth Dakta). 7/42 prgrams indicated that the prvisin will have an unknwn impact n cverage and cst-sharing. 1/7 prgrams cvered all recmmended vaccines and prhibited cst-sharing (Kentucky). 4/7 prgrams cvered all recmmended vaccines and permitted cst-sharing (Alaska, Califrnia, Maine, Mntana). 2/7 prgrams did nt cver all recmmended vaccines and permitted cst-sharing (Luisiana, Nrth Dakta). 10/42 prgrams indicated that the prvisin is under assessment r will likely impact cverage and cstsharing. 3/10 prgrams cvered all recmmended vaccines and permitted cst-sharing (Nebraska, New Yrk, Vermnt). Nebraska, New Yrk, and Vermnt respnded that the prvisin is under review. 1/10 prgrams cvered all recmmended vaccines and cst-sharing was unknwn (Delaware). Delaware respnded that they may need t identify applicable CPT cdes t claim the FMAP increase. 5/10 prgrams did nt cver all recmmended vaccines and permitted cst-sharing (Alabama, Clrad, Gergia, Mississippi, Suth Carlina). Alabama respnded that they may add cverage and exempt cst-sharing. Clrad respnded that the prvisin is under review, but csts t cver (zster vaccine) are greater than funds generated by the 1% 19

20 FMAP increase, and csts t change the cpayment system make the plicy even less cst effective. Gergia respnded that an FMAP increase may cver sme csts, but managing their large number f enrllees (650,000) will be difficult. Mississippi and Suth Carlina respnded that the prvisin is under review. 1/10 prgrams did nt cver all recmmended vaccines and cst-sharing was unknwn (Texas). Texas respnded that the Health and Human Services Cmmissin (HHSC) is currently evaluating the utilizatin f this ptin t btain a 1% FMAP increase and are awaiting further federal guidance. CONCLUSION This reprt examines hw Medicaid prgrams in the fifty states and the District f Clumbia address benefit design and cst-sharing plicy related t vaccinatin services fr nninstitutinalized adults enrlled in fee-fr-service prgrams. Additinally, prgram administratrs were asked t discuss their prgrams anticipated respnse t relevant prvisins in the ACA. Our research findings shw that 36 prgrams cver all ACIP recmmended vaccines, an increase frm 2003, when 32 states cvered all ACIP recmmended vaccines. Only Flrida fails t cver any vaccine in 2012, a decrease frm 2003, when 3 states did nt cver any vaccine fr adults. Prgrams that prhibited cpayments in 2012 increased by 21 frm 2003, when n prgram prhibited cpayments. The 25 prgrams that permit cpayments in 2012, charge frm $.50 t $3.40 r 5 percent f the allwable amunt the prgram permits the prvider t bill. The majrity f administratrs indicated that their prgrams will nt alter vaccine benefit cverage plicies in rder t receive incentives under the ACA. Medicaid prgrams cntinue t make prgress tward prviding ACIP recmmended vaccinatins fr adult enrllees. The prgrams that have nt achieved cverage t the ACIP level nte that cst is the primary factr limiting their ability t increase cverage. Because Medicaid enrllees are sensitive t cpayment plicies, each prgram shuld carefully cnsider cst-sharing requirements that bth sustain the prgram while eliminating unnecessary barriers t care. Each prgram will cntinue t evaluate the impact f ACA t determine whether the incentives ffered under the Act will increase the ability f the prgram t expand vaccine services. The study excluded data frm the 5 U.S. territries that participate in the Medicaid prgram and Medicaid managed care plans. Future research related t vaccinatins fr adults enrlled in Medicaid culd address these limitatins by including Medicaid prgrams perating in the Territries and thse with managed care plans. 1 The reprt is available at: pub_uplads/dhppublicatin_5f6fc d20-3d48db884f5c18c8.pdf 2 HwT.gv [Internet]. US General Services Administratin Office f Citizen Services and Innvative Technlgies: Basics f Survey and Questin Design; [updated 2013 Feb 19; cited 2013 Feb 21]. 20

21 Available frm: 3 SurveyMnkey Help Center [Internet]. Available Questin Types and Frmatting Optins; c [cited 2013 Feb 22]. Available frm: 4 Rsenbaum S, Stewart A, Cx M, Lee A. The epidemilgy f US immunizatin law: Medicaid cverage f immunizatins fr nn-institutinalized adults. Final reprt. Washingtn (DC): The Gerge Washingtn University, Schl f Public Health and Health Services; 2003 Nv. Available frm: pub_uplads/dhppublicatin_5f6fc d20-3d48db884f5c18c8.pdf 5 Enacted in 1965 under Title XIX f the Scial Security Act. 6 Medicaid: A Primer, Key Infrmatin n Our Natin s Health Cverage Prgram fr Lw-Incme Peple, p 3, The Henry J. Kaiser Family Fundatin, June 2010, 7 Klees BS, Wlfe CJ, Curtis CA. Brief summaries f Medicaid and Medicaid: title xvii and title xix f The Scial Security Act. Centers fr Medicare and Medicaid, DHHS Kaiser Family Fundatin. Medicaid, A Primer < p.1 9 American Sama, Guam, Mariana Islands, Puert Ric, and Virgin Islands. (SECTION 12 - SOCIAL WELFARE PROGRAMS IN THE TERRITORIEShttp://demcrats.waysandmeans.huse.gv/media/pdf/110/gb12.pdf). Accessed August 21, Medicaid (Hme Page), Natinal Cnference f State Legislatures, Accessed n August 21, US Department f Cmmerce. Incme, pverty, and health insurance cverage in the United States: Final reprt. Washingtn (DC): US Census Bureau; 2012 Sep. Reprt N. P Available frm: 12 Cngressinal Budget Office. Spending and enrllment detail fr CBO s February 2013 baseline: Medicaid. Feb Available frm: 13 US Department f Cmmerce. Incme, pverty, and health insurance cverage in the United States: Final reprt. Washingtn (DC): US Census Bureau; 2012 Sep. Reprt N. P Available frm: 14 Cngressinal Budget Office. Spending and enrllment detail fr CBO s February 2013 baseline: Medicaid. Feb Available frm: 15 Kaiser Family Fundatin. Medicaid, A Primer < p See The Faces f Medicaid: The Cmplexities f Caring fr Peple with Chrnic Illnesses and Disabilities, Center fr Health Care Strategies, Inc., available at 17 Schneider, A., Garfield, R., Chapter II: Medicaid Benefits, Medicaid and the Uninsured, p 52, The Henry J. Kaiser Family Fundatin, March Kaiser Family Fundatin. Medicaid, a primer. Final reprt. Washingtn (DC): Kaiser Cmmissin n Medicaid and the Uninsured; 2010 Jun. Reprt N Available frm: 19 Klees BS, Wlfe CJ, Curtis CA. Brief summaries f Medicaid and Medicaid: title xvii and title xix f The Scial Security Act. Final reprt. Baltimre (MD): Centers fr Medicare and Medicaid, Department f Health and Human Services; Available frm: Systems/Statistics-Trends-and- Reprts/MedicarePrgramRatesStats/dwnlads/MedicareMedicaidSummaries2009.pdf. 20 Swartz K. Health care fr the pr: Fr whm, what care, and whse respnsibility. Fcus (2): US Department f Health and Human Services. Immunizatin and infectius diseases bjectives: Washingtn (DC): Healthy Peple Available frm: 21

22 22 Centers fr Disease Cntrl and Preventin. Vaccinatin cverage estimates frm the Natinal Health Interview Survey: US Atlanta (GA): NCHS Health E-Stat; 2009 Jul. Available frm: 23 US Department f Health and Human Services. Immunizatin and infectius diseases bjectives: Washingtn (DC): Healthy Peple Available frm: 24 Takayama M, Wetmre CM, Mkdad AH. Characteristics assciated with the uptake f influenza vaccinatin amng adults in the United States. Preventive Medicine, 2012 Mar.54: di: /j.ypmed Keeler EB. Effects f cst sharing n use f medical services and health. Santa Mnica (CA): RAND Crpratin; Reprt N.: RP Available frm: 26 Wright BJ, Carlsn MJ, Edlund T, DeVe J, Gallia C, Smith J. The impact f increased cst sharing n Medicaid enrllees. Health Affairs Jul./Aug.;24(4): Centers fr Medicare & Medicaid Services. Medicaid.gv: Nn-disabled Adults. Department f Health and Human Services Ppulatin/Adults/Nn-Disabled-Adults.html 28 US Department f Cmmerce. Incme, pverty, and health insurance cverage in the United States: Final reprt. Washingtn (DC): US Census Bureau; 2012 Sep. Reprt N. P Available frm: 29 Pub. L. N , 2702, 124 Stat. 119, (2010). 30 Natinal Federatin f Independent Business v. Sebelius S. Ct. 2566; 183 L. 31 Department f Health and Human Services Health and Human Services pverty guidelines Feb. Available frm: 32 Sectin 1937 f the Scial Security Act (defining benchmark cverage as: the standard Blue Crss/Blue Shield PPO plan; state emplyee cverage; cverage thrugh HMOs; r secretary apprved cverage. Benchmark equivalent cverage includes well-baby and well-child care, including age-apprpriate immunizatins; and ther apprpriate preventive services designated s by the Secretary f HHS). 33 Guidance t state Medicaid Directrs n the EHBs, issued n Nvember 20, 2012, indicates that CMS intends t develp rules regarding Essential Health Benefits under Medicaid. CMS intends t prpse that the definitin and cverage prvisins fr EHBs generally apply t Medicaid, with mdificatins. CMS will wrk clsely with states t ensure that cverage f the ten statutrily-specified EHBs will apply t Medicaid. See: and Scial Security Online: Cmpilatin f the Scial Security Laws. Sec [42 U.S.C. 1396u-7]. OR Alexandra M. Stewart. The Affrdable Care Act: US Vaccine Plicy and Practice. The Gerge Washingtn University, Schl f Public Health and Health Services, Department f Health Plicy. Fall Title IV, Subtitle B, Sec Assistant Secretary fr Planning and Evaluatin (ASPE), Department f Health and Human Services. Federal Medical Assistance Percentages r Federal Financial Participatin in State Assistance Expenditures (FMAP). Nvember, 10, Scial Security Online: Cmpilatin f the Scial Security Laws. Sec [42 U.S.C. 1396d] Centers fr Disease Cntrl and Preventin. Recmmended adult immunizatin schedule US, MMWR 2012;61(4) 39 Rsenbaum S, Stewart A, Cx M, Lee A. The epidemilgy f US immunizatin law: Medicaid cverage f immunizatins fr nn-institutinalized adults. Final reprt. Washingtn (DC): The Gerge Washingtn University, Schl f Public Health and Health Services; 2003 Nv. Available frm: 22