MODULE 2 – Eligibility

http://www.cdc.gov/vaccines/programs/vfc/default.htm

Eligibility Criteria

Children through 18 years of age who meet at least one of the following criteria are eligible to receive VFC vaccine:

•	Medicaid eligible: A child who is eligible for the Medicaid program. (For the purposes of the VFC program, the terms "Medicaid-eligible" and "Medicaid-enrolled" are equivalent and refer to children who have health insurance covered by a state Medicaid program) 

•	Uninsured: A child who has no health insurance coverage

•	American Indian or Alaska Native: As defined by the Indian Health Care Improvement Act (25 U.S.C. 1603)

•	Underinsured: A child who has commercial (private) health insurance but the coverage does not include vaccines, a child whose insurance covers only selected vaccines (VFC-eligible for non-covered vaccines only), or a child whose insurance caps vaccine coverage at a certain amount. Once that coverage amount is reached, the child is categorized as underinsured. Underinsured children are eligible to receive VFC vaccine only through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC).

Children whose health insurance covers the cost of vaccinations are not eligible for VFC vaccines, even when a claim for the cost of the vaccine and its administration would be denied for payment by the insurance carrier because the plan's deductible had not been met.

The State Children's Health Insurance Program (SCHIP), known as Title XXI, enables states to expand health insurance coverage for uninsured children. Title XXI children enrolled in a separate State Children Health Insurance Program are not VFC-eligible because these children are considered insured. Title XXI children enrolled in a Medicaid-expansion SCHIP program are Medicaid eligible and entitled to VFC program benefits. Some states have implemented their SCHIP programs as a combination plan with some children becoming Medicaid eligible through an expansion plan and some children enrolled in a separate SCHIP. The Medicaid-eligible children are entitled to VFC program benefits, and the children enrolled in the separate SCHIP program are considered insured and are not entitled to VFC program benefits. 

What is an FQHC?

An FQHC is a health center that is designated by the Bureau of Primary Health Care (BPHC) of the Health Services and Resources Administration (HRSA) to provide health care to a medically underserved population. FQHCs include community and migrant health centers, special health facilities such as those for the homeless and persons with acquired immunodeficiency syndrome (AIDS) that receive grants under the Public Health Service (PHS) Act, and "look-alikes," which meet the qualifications but do not actually receive grant funds. They also include health centers within public housing and Indian health centers. 

What is an RHC?

An RHC is a clinic located in a Health Professional Shortage Area, a Medically Underserved Area, or a Governor-Designated Shortage Area. RHCs are required to be staffed by physician assistants, nurse practitioners, or certified nurse midwives at least half of the time that the clinic is open.

Provider Responsibility to Screen for VFC Eligibility

Screening to determine a child's eligibility to receive vaccines through the VFC Program must take place with each immunization visit, although the screening form need be replaced or updated only if the status of the patient changes. The patient eligibility screening record provides a means of recording parent responses to VFC eligibility questions. The parent, guardian or provider may complete this form (see Appendix 3). Verification of parent/guardian responses is not required. To maximize efficiency, providers may elect to incorporate these screening questions into an existing form; however, any revision must include the core screening information listed on the CDC-developed form and be approved by the state Immunization Program. Patient eligibility screening records should be maintained on file for a minimum of 3 years after service to the patient has been completed unless state law/policy establishes a longer archival period. VFC eligibility screening is discussed in more detail in Module 3.