State Medicaid Levers to Promote Immunization: California’s Experience

Vaccines are a powerful and cost-effective tool to prevent diseases and save lives. Once common, deadly diseases such as polio, measles, and mumps are preventable and smallpox no longer exists outside of a laboratory. According to research estimates, of 4.3 million infants born in the United States in 2009, vaccines will prevent 40,000 deaths and 20 million illnesses over their lifetimes. Vaccinating children is also cost effective, saving $10.20 for every $1 spent on immunizations.

Despite these successes, states are working to improve their immunization rates, which hovered at 68.4 percent nationwide in children ages 19 to 35 months in 2012. California is using an assortment of strategies and inducements to boost its immunization rates.

How Can States Increase Immunization Rates through Medicaid?

Medicaid plays a key role in the delivery of vaccines, especially among vulnerable populations including children and pregnant women. Because Medicaid covers a large percentage of US children (39 percent), increasing childhood immunization rates among Medicaid beneficiaries can generate significant long-term savings. US Centers for Disease Control and Prevention (CDC) officials estimate that vaccinating children born between 1994 and 2018 has saved the United States about $300 billion in direct medical costs and $1.38 trillion in total costs, and protected millions from serious diseases.

State Medicaid programs can employ a variety of levers to increase immunization rates among their beneficiaries, from ensuring access and coverage for vaccines to tracking targeted metrics that inform provider incentive payments and reimbursement. These levers include:

  • Providing comprehensive coverage: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) is Medicaid’s benefit for children and adolescents younger than 21, as described in Sec. 1905(r) of the Social Security Act. The EPSDT benefit requires that states provide all vaccines recommended by the Advisory Committee on Immunization Practice (ACIP) to all children eligible for EPSDT benefits.
  • Making vaccine available: Through the Vaccines for Children (VFC) program, the CDC purchases vaccines at a discount and distributes them to state health departments and other local and territorial public health agencies. These entities distribute the vaccines to private and public health providers who are registered as VFC Children are eligible for VFC-funded vaccines if they are younger than 19 and Medicaid-eligible, uninsured, American Indian or Alaska Native, or underinsured and vaccinated in certain settings. VFC-eligible children receive recommended vaccines at no cost when administered by a registered VFC provider.
  • Using metrics: The US Department of Health and Human Services sets annual Medicaid and Children’s Health Insurance Program (CHIP) health care quality measures to ensure providers deliver appropriate care to their patients. The 2019 Medicaid and CHIP Core Set of Children’s Health Care Quality Measures includes the Healthcare Effectiveness Data and Information Set (HEDIS) Childhood Immunization Status measure.* Monitoring and measuring changes in vaccine delivery through this metric is a critical step to improving targeted immunization rates.
  • Using incentive measures: State Medicaid programs can use incentive payments to increase immunization uptake. For example, evidence shows that incentive payments to providers through Medicaid pay for performance programs increases childhood immunization rates.
  • Performance improvement projects (PIPs): State Medicaid programs can encourage managed care organizations (MCOs) to focus on improving immunization rates by including it as one of their PIPs. Medicaid MCOs participate annually in PIPs.
  • Form partnerships to strengthen immunization efforts: Multiple state agencies play an important role in increasing immunization rates. Medicaid and public health agencies can partner with other stakeholders to address mutual goals.
  • Data sharing: States have various data sources from different agencies that may include information on vaccination status. This includes immunization information systems (IIS), which are confidential, population-based computerized registries that record vaccination doses and are usually maintained by public health departments, and Medicaid Management Information Systems (MMIS), which contain Medicaid claims data. Data exchanges between IIS and MMIS can help identify missed opportunities for vaccination, monitor gaps in immunization coverage, and improve vaccination rates.

California’s Strategies

A Healthy People 2020 immunization target is to increase the percentage of children ages 19 to 35 months who receive the recommended doses of diphtheria, tetanus, and pertussis (DTaP), polio, mumps-measles-rubella (MMR), Hib (meningitis), hepatitis B, varicella and pneumococcal conjugate vaccine (PCV) to 80 percent, from the 2012 average of 68.4 percent. As of 2017, California’s combined seven-vaccine series coverage rate among children ages 19 to 35 months was 68.6 percent. California’s health-related agencies have been working over the last several years to increase the state’s childhood immunization rates. Medi-Cal, California’s Medicaid Program, covers 43 percent of children in the state, so Medi-Cal has strong incentives to work to improve vaccination rates among its beneficiaries. Medi-Cal uses the following levers to reach this goal.

  • Comprehensive coverage: The California Department of Health Care Services (DHCS) administers the EPSDT benefits to all low-income youth enrolled in Medi-Cal consistent with the federally mandated benefit. Pregnant women (of any age) and all children younger than 21 are eligible for Medi-Cal if they meet income limits.
  • Vaccine availability: Medi-Cal participates in the VFC program to ensure that vaccines are eligible at no charge to public and private providers for eligible children. DHCS reimburses enrolled providers the administrative fee per dose of vaccine. In 2018, the California Department of Public Health (CDPH) distributed approximately $665 million worth of ACIP-recommended pediatric vaccines through the VFC program. Immunizations are also a medical and pharmacy benefit for all adult Medi-Cal members, including pregnant women.
  • Metrics: California’s Medi-Cal program collects the HEDIS measure “Childhood Immunization Status” from all of its MCOs, which requires the administration of the 10 ACIP-recommended vaccines by age two. MCOs are required to meet a minimum performance benchmark on the childhood immunization measure – 50 percent of all Medicaid health plans nationally, as determined by the National Committee for Quality Assurance). When MCOs do not meet the benchmark, quality improvement work is required, sanctions are imposed, and corrective action may be imposed. MCOs are contractually required to document each member’s need for ACIP-recommended immunizations as part of all regular health visits, and to ensure that all children receive ACIP-recommended immunizations at any health care visit.
  • Incentive measures: California’s Medi-Cal program operates a directed payment Quality Incentive Program (QIP) that directs MCOs to make QIP payments to designated public hospital systems tied to performance on specific performance metrics, including the Childhood Immunization Status and Immunization for Adolescents measures. As part of California’s 1115 Waiver, Medi-Cal provides incentive payments to designated public hospital and district and municipal hospital systems tied to performance on specific performance metrics, including the Influenza Immunization measure for members ages six months and older [California’s Public Hospital Redesign and Incentives in Medi-Cal (PRIME) program]. In addition, California’s Medi-Cal Value-Based Payment Program provides an incentive payment to providers for administration of several vaccinations, including the pertussis vaccine to women who are pregnant (supporting the HEDIS Prenatal Immunization Status Measure), the influenza vaccine to adults 19 years and older, and the last dose of any of the multiple-dose vaccine series given on or before a child’s second birthday (DTaP, polio, hepatitis B, Hib, pneumoconccal conjugate, rotavirus, and influenza), supporting the Childhood Immunization Status measure.
  • Performance improvement projects (PIPs): In 2016, DHCS identified improving childhood immunization rates as one focus topic for its PIP because less than three-quarters of young children enrolled in Medi-Cal were fully immunized, and immunization is an area with quantified health disparities, especially within the Medicaid program. Between 2015 and 2017, five health plans participated in PIPs to improve immunizations of two-year-olds. In 2018, health plans with low or declining performance on the HEDIS childhood immunization indicator were required to participate in a childhood immunization-focused PIP. Between 2017 and 2019, 15 health plans participated in PIPs to improve childhood immunization rates. Beginning in the fall of 2019, health plans will embark on their third round of PIPs, one of which will focus on childhood and adolescent health. To date, seven health plans have submitted PIP-focused proposals to improve childhood immunization rates. Separate from the PIPs, as noted above, when health plans do not meet the required performance benchmark for the childhood immunization measure, DHCS requires those plans to conduct a rapid cycle quality improvement project to improve their immunization rates. DHCS is striving to increase its overall managed care childhood immunization rate to at least 80 percent coverage.
  • Partnerships that strengthen immunization efforts: Medi-Cal partners with multiple stakeholders, including CDPH and other state agencies, health care providers, and other private entities. CDPH provides technical assistance to public and nonprofit health clinics, participates in the multi-sector California Immunization Coalition, and assists schools and childcare centers in complying with state immunization requirements.

CDPH continues to develop and support efforts to address disparities in immunizations of minority and uninsured children, including a focus on increasing prenatal immunization with the TDaP vaccine among pregnant Latina women. In 2015, CDPH undertook several initiatives, including the DHCS National Governor’s Association Learning Collaborative, to increase prenatal immunization rates.

  • Data sharing: California’s IIS – the California Immunization Registry (CAIR) – supports immunization by:
    • Providing a comprehensive immunization record that can adapt to changes in the medical home or health insurance;
    • Calculating which shots children need and minimizing under- or over-immunization;
    • Issuing reminders of upcoming visits; and
    • Identifying individuals and populations with low immunization rates.

The Medi-Cal program requires its MCOs to ensure that immunizations are reported to the registry. California physicians’ offices, clinics, families, and schools are estimated to have saved several millions of dollars annually as a result of the registry.**

California uses strategic levers to increase immunization rates in its Medicaid population, including identifying the target populations’ EPSDT benefits, identifying metrics for quality improvement programs, and developing strategies to incentivize providers to improve their immunization rates. These levers enable the Medicaid agency to contribute as a critical partner to a strong state partnership supporting a comprehensive strategy for improving immunization rates.

* Percentage of children age two who received four diphtheria, tetanus and acellular pertussis (DTaP); three polio; one measles, mumps and rubella (MMR); three haemophilus influenzae type B; three hepatitis B, one chicken pox; four pneumococcal conjugate; one hepatitis A; two or three rotavirus; and two influenza vaccines by their second birthday. This measure calculates a rate for each vaccine and nine separate combination rates.

** California Immunization Registry (CAIR) users include health care providers, public health departments, schools, childcare facilities, family child care homes, WIC service providers, foster care agencies, welfare departments, juvenile justice facilities, and other programs that provide, track, or promote immunization.


Acknowledgements: The National Academy for State Health Policy (NASHP) would like to thank Mary Beth Hance at the Center for Medicare and Medicaid Services, Megan Lindley and Aaron Borrelli at the Centers for Disease Control and Prevention (CDC), Sarah Royce at the California Department of Public Health and Linette Scott at the California Department of Health Care Services for their time and insights, which made this blog possible. The author also wishes to thank Trish Riley and Jill Rosenthal for their contributions to this case study. Any errors or omissions are the author’s. This project is supported by the CDC. This information or content and conclusions are those of the authors.