VFC Program Eligibility & Billing Scenarios

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

Click here to download a PDF version.

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.

Scenarios 1-7 are listed on page 1. Scenarios 8-12 are listed on page 2.

Scenario 1:
Patient presents age 19 years or older.

Patients age 19 years and over are not eligible for publicly-funded vaccine regardless of insurance status. Eligibility ends for all children as of their 19th birthday.

Scenario 2:
Patient presents with private health insurance which covers vaccines.

Patients whose health insurance plan includes vaccine as a covered medical service are considered insured. They are not eligible for publicly-funded vaccine.

Scenario 3:
Patient presents with private health insurance which has a deductible or co-payment.

Patients whose health insurance plan includes vaccine as a covered medical service, regardless of deductibles or co-payments, are considered insured. They are not eligible for publicly-funded vaccine.

Scenario 4:
Patient presents with a medical savings account or health savings account.

Patients covered by a medical or health savings account must also have a high deductible health plan. They are considered insured and are not eligible for publicly-funded vaccine. [A flex spending account is not a medical or health savings account and does not affect eligibility for publicly-funded vaccine.]

*Scenario 5:
Patient presents with private health insurance which has no vaccine coverage.

Patients whose health insurance plan does not include vaccine as a covered medical service are considered under-insured. They are eligible to receive publicly-funded vaccine, but only in a Federally Qualified Health Center or Rural Health Center (FQHC/RHC)*.

*Scenario 6:
Patient presents with private health insurance which has an annual vaccine coverage cap.

Patients whose health insurance plan caps vaccine coverage at an annual limit, after which there is no vaccine coverage are considered under-insured. They are eligible to receive publicly-funded vaccines, but only in a Federally Qualified Health Center or Rural Health Center (FQHC/RHC)*. The patient’s coverage must be depleted before they are considered under-insured.

*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).*

*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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