VFC is a federal entitlement program designed to reduce or eliminate vaccine cost as a barrier to childhood vaccination. The program purchases vaccines from manufacturers at federal contract prices and provides them at no cost to participating public and private healthcare providers for use in children through age 18 years who are eligible for Medicaid, are uninsured, or are American Indian or Alaska Native. VFC also includes the RSV preventive antibody product (nirsevimab) recommended for all infants. Children whose health insurance benefit plan does not cover one or more vaccines included in VFC, or whose insurance plan has a fixed dollar cap for vaccines (after the cap is reached) are considered “underinsured” and are also able to receive VFC vaccine at a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC). This type of limited coverage plan is now uncommon because the Affordable Care Act (ACA) requires ACA-compliant plans to cover ACIP-recommended vaccines with no deductible or copay.
If you are interested in becoming a VFC provider, you should contact your state immunization program. For more information on the VFC program in general, go to the CDC’s website at?www.cdc.gov/vaccines-for-children/about/index.html.
Last reviewed:
February 14, 2025
If the child has no health insurance on the day he or she presents at a medical practice or health department for immunization, the child is VFC eligible because he or she is uninsured. A child must be screened for VFC eligibility at each visit, even though the eligibility form needs to be updated only when the child’s eligibility status changes.
Last reviewed:
February 14, 2025
Because of the Affordable Care Act (ACA), all ACA-compliant commercial insurance plans must cover all vaccines included in the recommended immunization schedule for children and adults with no deductible or copay requirement; this includes vaccines on the schedule that are not routine, but are recommended following shared clinical decision-making (such as meningococcal B vaccine for healthy people age 16 through 23). A child who has a form of health insurance that is not ACA-compliant (may be referred to as a grandfathered plan) but which covers the cost of vaccinations as a benefit is not eligible for VFC vaccines, even if the plan requires a copay or requires that they meet a deductible for the year.
Last reviewed:
February 14, 2025
No. The CDC states that the only criteria are age (age 18 years or younger) and one of the following four factors:
- Uninsured
- American Indian/Alaska Native
- Medicaid-eligible
- Underinsured (insurance benefit does not cover the needed vaccine as a benefit and child is receiving vaccine in a federally qualified health center or rural health center)
No other factors (including residency status) can be considered when screening for eligibility requirements for the VFC program.
Last reviewed:
February 14, 2025
Medicare Part B (which primarily covers medical outpatient care costs) covers four recommended vaccines for all Medicare beneficiaries: COVID-19, hepatitis B (whether or not a risk factor is reported), influenza, and recommended pneumococcal conjugate and pneumococcal polysaccharide vaccines. Medicare Part B does not cover other adult vaccinations (e.g., Tdap) unless they are directly related to the treatment of an injury or direct exposure to a disease, such as anti-rabies treatment or tetanus prevention due to an injury. In the absence of injury or direct exposure, all other vaccines, including zoster, are covered by Medicare Part D.
Medicare Part D plans (outpatient prescription drug insurance) cover the Advisory Committee on Immunization Practices (ACIP) recommended vaccines that Part B does not cover (for example, RSV and zoster). Since early 2023, the Inflation Reduction Act of 2022 has required Medicare Part D plans to cover ACIP-recommended adult vaccinations without a deductible or copay when given by an in-network provider. Medicare Part D coverage also includes ACIP-recommended vaccines recommended for an individual as a result of occupational or travel-related risks. A summary of adult vaccine insurance coverage can be found at www.izsummitpartners.org/content/uploads/NAIIS_Vaccine-insurance-coverage-2024-2025.pdf.
Last reviewed:
February 14, 2025
All commercial insurance plans compliant with the Affordable Care Act (ACA) should cover vaccines listed on the CDC’s recommended schedules for vaccines for children and adults without any cost-sharing (e.g., no deductible or copay) when given by in-network providers.
The Inflation Reduction Act (IRA) of 2022, which was fully enacted during 2023, substantially reduced cost-related barriers to vaccination for adults. The law eliminated cost-sharing for ACIP-recommended vaccination of all adults covered by traditional Medicaid and Medicaid expansion plans, as well as adults with Medicare Part D. ?More information about the ACA and IRA legislation impact on vaccine payment is available in this pdf report published by Avalere on October 2, 2023:? https://avalere.com/wp-content/uploads/2023/10/Guide-to-Vaccine-Coverage-Policies.pdf.
The National Adult and Influenza Immunization Summit (NAIIS) has created a web section with resources on billing and coding for adult vaccinations at?www.izsummitpartners.org/naiis-workgroups/access-provider-workgroup/coding-and-billing.
Last reviewed:
February 14, 2025
The Inflation Reduction Act of 2022 (IRA) requires “first-dollar” coverage (no out-of-pocket cost to patient) for all recommended vaccines for adults covered by traditional Medicaid or Medicaid expansion plans. This coverage requirement applies to all states; however, enforcement policies and implementation may vary by state. Providers should check with their state Medicaid program directly about vaccine payment coverage and amounts paid by specific state plans.
Last reviewed:
February 14, 2025
