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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 5:

Children must meet at least one of the VFC eligibility criteria (in this case described most likely as un-insured) to qualify for the VFC Program initially. VFC vaccine cannot be used unless the patient is eligible for the VFC Program. You cannot replace your private stock from VFC at a later date. At the next visit, upon VFC screening/confirmation of coverage by Medicaid, the patient could be eligible for VFC.

Scenario 6:

Patient presents for vaccines and states insurance covers vaccines. Private stock used and billed for. Claim process shows patient was incorrect – no vaccine coverage is indicated. Do we bill the patient or credit the account and replace our private stock with VFC? Does this make them underinsured?

Your office made a decision for service based on the patient’s statement of insurance coverage. Patient accounts should be settled according to your office policies, as with any other service you provide.

You cannot later replace your private stock with VFC. Information related to insurance coverage should be noted on the patient’s chart. Any changes to the patient’s insurance coverage become effective with the next services. At the next visit, upon VFC screening or confirmation of coverage, the patient could be eligible for VFC. In this particular scenario, the patient would be considered under-insured.

Scenario 7:

Patient presents for vaccines and states insurance does not cover vaccines. VFC vaccine is used. Provider finds out on a subsequent visit that insurance does cover. What would we do?

 Patient eligibility for the VFC Program is determined by the patient’s declaration at the time of presentation for service. Any subsequent change in insurance coverage should be documented in the patient’s record for future services.

Scenario 8:

Patient’s insurance company pays for some vaccines and not others.

As of January 2001, Utah, using a provision in the federal rules, expanded VFC services by allowing under-insured children to be served through any VFC provider. Children whose health insurance benefit plan includes vaccines, but a specific VFC vaccine antigen is not covered by the plan, are considered under-insured for purposes of that particular vaccine at that visit. However, eligibility must be reviewed for future immunizations.

The state policy, approved by the Utah Scientific Vaccine Advisory Committee and implemented in January 2001 (revised January 2006), provides the following definition for under-insured: children whose insurance plan does not include vaccines, whose health insurance plan covers only select vaccine antigens, or caps the vaccine cost at a yearly or annual limit after which there is no vaccine coverage for that year.

Developed: 09/2002
Revised: 01/2006

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