DEPARTMENT OF HEALTH & HUMAN SERVICES 
Centers for Medicare & Medicaid Services 
7500 Security Boulevard, Mail Stop S2-26-12 
Baltimore, Maryland 21244-1850 
 
Center for Medicaid and State Operations 
 
 
                  SMDL #04-008 
         
December 14, 2004  
     
Dear State Medicaid Director:  
 
The purpose of this letter is to clarify the procedures for assuring that Medicaid enrolled 
children who are eligible for the Vaccines for Children (VFC) Program (i.e., children 
younger than 19 years of age) receive their influenza shots.  We want to stress that 
Medicaid providers should be vaccinating high priority VFC-eligible, Medicaid enrolled 
children with influenza vaccine they have on hand, regardless of whether the vaccine is 
available under the VFC program, when children present themselves at the providers 
office.  We also want to assure that Medicaid providers are appropriately reimbursed for 
the flu vaccines they provide to VFC-eligible, Medicaid enrolled children and that State 
Medicaid agencies receive federal reimbursement at the usual matching rate when 
appropriate. 
 
The Advisory Committee on Immunization Practices (ACIP), an advisory committee to 
the Secretary of Health and Human Services and the Centers for Disease Control and 
Prevention (CDC), has identified the following high priority children to be vaccinated 
against influenza this year under the VFC Program:  
 
(cid:131)  Children aged 6 months through 23 months. 
(cid:131)  Children and adolescents aged 2 through 18 years with chronic disorders of the 
pulmonary or cardiovascular systems, including asthma. 
(cid:131)  Children and adolescents aged 2 through 18 years who have required regular 
medical follow-up or hospitalization during the preceding year because of 
chronic metabolic diseases (including diabetes mellitus), renal dysfunction, 
hemoglobinopathies, or immunosuppression (including immunosuppression 
caused by medications or by human immunodeficiency virus [HIV]). 
(cid:131)  Children and adolescents aged 2 through 18 years who are receiving long-term 
aspirin therapy and may therefore be at risk for developing Reye syndrome after 
influenza. 
(cid:131)  Children and adolescents aged 2 through 18 years who are residents of nursing 
homes and other long-term care facilities that house persons at any age who have 
chronic medical conditions. 
(cid:131)  Adolescent females aged <19 years who will be pregnant during the influenza 
season. 
(cid:131)  Children and adolescents aged 2 through 18 years who are household contacts or 
out-of-home caregivers of children aged <6 months. 
  Page 2  State Medicaid Director 
 
Many Medicaid providers will receive influenza vaccine from both the VFC Program and 
private sources.  Medicaid providers with vaccine from both sources should take care to 
use the VFC vaccine only for federally vaccine-eligible high priority children and 
privately purchased vaccine for non-VFC-eligible high priority children.  However, in the 
event a Medicaid provider does not have VFC supply on hand to vaccinate a high priority 
VFC-eligible Medicaid enrolled child, the provider should use vaccine from private 
stock, if available. The provider should not turn away, refer or reschedule that child for a 
later date, if vaccine is available. In instances where a VFC-eligible Medicaid child is 
vaccinated from private stock, the provider could either provide a replacement dose if 
VFC vaccine becomes available on a timely basis during this influenza season or, if no 
future VFC shipments are expected on a timely basis, bill the state Medicaid program 
directly for the vaccine itself and for administering the vaccine.  The state Medicaid 
program will reimburse the Medicaid provider for both the vaccine as well as for 
administering the vaccine to high priority VFC-eligible Medicaid enrolled children and 
the Centers for Medicare & Medicaid Services (CMS) will match the states expenses at 
the usual federal matching rate.  Please note that Medicaid payment applies to 
vaccinations received by VFC-eligible Medicaid enrolled children but not to other 
federally vaccine-eligible children (i.e., American Indians/Alaska Natives, uninsured, and 
underinsured children served in a federally qualified health center or rural health center) 
who are not also enrolled in Medicaid.  
 
There may be some instances where a Medicaid provider needs to borrow vaccine from 
VFC stock in order to vaccinate high priority, privately insured children.  The VFC 
Program has a policy of allowing VFC/Medicaid providers to borrow limited VFC 
influenza vaccine doses to vaccinate such individuals as long as such loan/borrowing is 
adequately documented and the doses are replaced on a timely basis. Therefore, it is 
important that a Medicaid provider should only vaccinate a high priority, privately 
insured person using VFC vaccine, if the provider expects a shipment of private vaccine 
in the coming weeks that will replace the VFC vaccine borrowed and the provider has 
enough VFC doses available to assure that no VFC-eligible children will be turned away 
in the meantime. 
 
Providers with insufficient influenza vaccine supply to vaccinate their high priority 
Medicaid children should contact their state and local health departments to determine if 
additional vaccine is available to order and to seek guidance regarding any efforts to 
reallocate vaccine among providers.  If these providers are out of all vaccine stock, they 
should refer their Medicaid enrolled patients to other Medicaid providers in the 
community if they know these providers have influenza vaccine in stock.  
 
Because there is increased demand for influenza vaccine this season, Medicaid providers 
should:  ensure that parents/guardians and patients are educated about the benefits and 
risks of vaccination in a culturally appropriate manner and in understandable language; 
follow appropriate procedures for vaccine storage, handling, and documentation of 
vaccine administration; have systems in place to outreach to high priority Medicaid   Page 3  State Medicaid Director 
 
enrolled children; and remind parents/guardians of high priority children due for 
vaccination, including children requiring a second dose of influenza vaccine. 
 
Medicaid enrolled children under the age of 19 are VFC-eligible and are the focus of the 
above discussion.  However, under the Early and Periodic Screening, Diagnostic, and 
Treatment (EPSDT) services/benefit, Medicaid enrolled children under 21 years of age 
are required to be vaccinated based on the ACIP recommendations.  Therefore, States 
also must cover and reimburse for influenza vaccinations provided to Medicaid enrolled 
children ages 19 and 20 years of age who fall into an ACIP high priority group. (CDC's 
Web site at www.cdc.gov/nip/flu identifies the high priority groups of children and adults 
recommended by the ACIP for influenza vaccination this season.)  Note also that states 
that cover influenza vaccinations for adults 21 years of age or older as an optional 
Medicaid benefit should refer to the CDC website.  Except as noted previously, private 
vaccine stock should be used to vaccinate high priority Medicaid enrolled persons who 
are not eligible for the VFC Program. 
 
Please address any questions to Ms. Jean Sheil, Director of the Family and Childrens 
Health Program Group at 410-786-5647.  Please note that CDC has concurred with the 
contents and message in this letter. 
 
            Sincerely, 
 
            /s/ 
 
            Dennis G. Smith 
            Director 
 
cc:  
CMS Regional Administrators 
  
CMS Associate Regional Administrators  
    for Medicaid and State Operations  
 
Kathryn Kotula  
Director, Health Policy Unit  
American Public Human Services Association  
 
Joy Wilson  
Director, Health Committee  
National Conference of State Legislatures  
 
Matt Salo  
Director of Health Legislation  
National Governors Association  Page 4  State Medicaid Director 
  
Brent Ewig  
Senior Director, Access Policy  
Association of State and Territorial Health Officials 
  
Jim Frogue  
Director, Health and Human Services Task Force  
American Legislative Exchange Council 
  
Trudi Matthews  
Senior Health Policy Analyst  
Council of State Governments