IMM - VFC

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Utah Vaccines For Children Program
Eligibility and Billing Scenarios
Effective January 1, 2012

These scenarios are provided to help providers determine if a patient is eligible for publicly funded vaccine through the Utah VFC Program at the time of service. All scenarios were reviewed with the Centers for Disease Control and Prevention (CDC) and Utah Medicaid.

*Scenario 7:

Patient presents with private health insurance which covers only selected vaccines.

Patients whose health insurance plan includes coverage for only selected vaccines are considered under-insured, for non-covered vaccines. They are eligible to receive publicly funded vaccines, but only in a Federally Qualified Health Center or Rural Health Center (FQHC/RHC).*

Scenario 8:

Patients presents with private health insurance and Medicaid.

All children who are Medicaid recipients are eligible to receive publicly funded vaccine regardless of private health insurance coverage. The provider should administer VFC vaccine and bill the administration fee to Medicaid. Medicaid will pay the administration fee and seek reimbursement from the primary insurance.

Scenario 9:

Patient presents and has applied for Medicaid and/or Children’s Health Insurance Program (CHIP).

Patients must meet at least one VFC eligibility criteria at the time of service in order to receive publicly funded vaccine. The patient is not enrolled in Medicaid or CHIP at the time of service but should be screened for VFC eligibility under other categories (ie: un-insured, American Indian/Alaskan Native, or under-insured*).

Scenario 10:

Patient presents with private health insurance and Medicaid pending. Patient states health insurance plan includes vaccine coverage. Private vaccine is administered. Insurance plan denies payment for vaccine. Medicaid is made retroactive.

The patient was not enrolled in Medicaid and was not eligible to receive publicly funded vaccine at the time of service. VFC eligibility cannot be changed retroactively and providers cannot replace private vaccine with VFC vaccine at a later date. The provider may seek payment for the administration fee from Medicaid under the retroactive payment. At the next visit, upon VFC screening and confirmation of Medicaid coverage, the patient would be eligible to receive publicly funded vaccine.

Scenario 11:

Patient presents with private health insurance. Patient states health insurance plan includes vaccine coverage. Private vaccine is administered and insurance plan billed. Claim process shows patient was incorrect and vaccine is not a covered medical service.

Patient eligibility for publicly funded vaccine is determined by the patient’s declaration at the time of service. VFC eligibility cannot be changed retroactively and providers cannot replace private vaccine with VFC supplied vaccine at a later date. The provider may seek payment from the patient and their account should be settled according to internal office policies, as with any other medical service provided.

Information related to insurance coverage should be noted in the patient’s record. At the next visit, upon VFC screening and confirmation of coverage, the patient could be considered under-insured and eligible to receive publicly funded vaccine, but only in a Federally Qualified Health Center or Rural Health Center (FQHC/RHC)*.

Scenario 12:

Patient presents as eligible for publicly funded vaccine and VFC vaccine is administered. Provider discovers at a later date patient was not eligible for publicly funded vaccine on that date of service.

Patient eligibility for publicly funded vaccine is determined by the patient’s declaration at the time of service. VFC eligibility cannot be changed retroactively and providers cannot replace VFC supplied vaccine with private vaccine at a later date. The patient should not be charged for the VFC vaccine and the VFC vaccine should be documented in the VFC Quarterly Doses Administered Report based on eligibility at the time of service. Any change related to VFC eligibility should be noted in the patient’s medical record for future services.

*As of January 1, 2012, under-insured patients may only receive publicly funded vaccine in a Federally Qualified Health Center or Rural Health Center (FQHC/RHC). Under-insured children cannot to be considered un-insured for the purpose of obtaining publicly funded vaccine. This is considered fraud and abuse of the Utah VFC Program.

Developed: 09/2002
Revised: 01/2012

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