Click here to download PDF version.

Utah Vaccines For Children Program
Eligibility Billing Scenarios
Effective January 1, 2006

These scenarios are provided to assist the provider in determining if a patient is VFC eligible. All scenarios were reviewed with Utah Medicaid.

Scenario 1:

Patient presents with private insurance or private insurance with high deductibles.

Patients whose insurance policy provides for immunizations as a covered medical service, regardless of deductibles are considered insured. They are not eligible for publicly funded vaccine.

The CDC State Immunization Program Operations Manual defines those with high deductibles as under-served, BUT
there are no funds, federal or state, to cover any child whose insurance provides for immunizations as a covered medical service where deductibles exist as a part of the policy.

Scenario 2:

Patient presents with private insurance or private insurance with low yearly or annual coverage caps.

Patients whose insurance policy provides for immunizations as a covered medical service are considered insured and are not eligible for publicly funded vaccine. However, if the vaccine cost is capped at a yearly or annual limit after which there is no vaccine coverage for that year, they are considered under-insured. The vaccine cap must be completely depleted to be considered as under-insured.

Scenario 3:

Patients presents with private insurance and Medicaid.

Children who are Medicaid recipients are eligible to receive VFC vaccine. Medicaid is NOT the payer of last resort with VFC. Medicaid may be billed for the administrative fee. However, only a small fraction of children in Utah have dual coverage through Medicaid and private insurance. If you bill Medicaid, you cannot bill private insurance for VFC vaccines.

Scenario 4:

Patient presents for vaccines and has insurance with Medicaid pending. Patient states policy covers vaccine. Private stock is given due to assumed insurance coverage. Policy denies payment for vaccines. Medicaid is made retroactive. Do we replace private stock? Do we use VFC initially?

This patient is not enrolled in Medicaid at the time of presentation to your office and therefore, is not eligible for VFC. You cannot use VFC initially or replace your private stock from VFC at a later date. At the next visit, upon VFC screening or confirmation of Medicaid coverage, the patient would be eligible for VFC. You may recoup the administration fee from Medicaid under the retroactive payment.

Page 1 | 2

Back to Top

Home | Public Information | Provider Information | Events Calendar | Newsletter | Contact | Sitemap | Help | Disclaimer | Privacy Policy

© Copyright 2001 Immunization Program Utah Department of Health
All rights reserved