Appendix A Well Child Check-Up (EPSDT)

Well Child Check-Up
This nationally sponsored program offers free vaccines to family and general
practitioners, pediatricians, hospital nurseries, emergency rooms, and other
qualified providers for children aged 18 years and under who are Medicaid
enrolled and eligible, have no health insurance, or are American Indian or
Alaskan Native. Free vaccines are also available to children who do not have
health insurance for immunizations (“underinsured”), if they obtain those
vaccines from a Federally Qualified Health Center or Rural Health Clinic.
Participation in Medicaid is not required for VFC enrollment; however, over
400,000 of Alabama’s children are Medicaid enrolled.
A.6.1
Fees
Medicaid has taken the past vaccine and administration fee costs and calculated
an equivalent reimbursement fee of $8.00 per dose. When multiple doses are
given on the same visit, Medicaid will reimburse for each dose. When doses are
given in conjunction with an EPSDT screening visit, an administration fee of
$8.00 per dose will also be paid. When doses are given in conjunction with an
office visit, an administration fee of $8.00 per dose will also be paid. Providers
are encouraged to utilize licensed available combination vaccines when
indicated, rather than the individual components of the vaccine.
Providers should use the immunization(s) procedure code designated by the
VFC Program when billing for the administration of an immunization. Please refer
to section A.6.3 for the list of designated VFC procedure codes.
Medicaid VFC providers may give VFC vaccines to children who are Medicaid
enrolled, non-Medicaid, uninsured, American Indian, or Alaskan Native. If a VFC
vaccine is given to any of the above patients, with the exception of Medicaid
enrolled, an administration fee not to exceed $14.26 for each vaccine
administered may be charged. Underinsured patients must go to an FQHC,
RHC, or county health department to receive VFC vaccines. An administration
fee not to exceed $14.26 for each vaccine administered may be charged. No
VFC-eligible patient should be denied immunizations because of an inability to
pay the administration fee.
Physicians and health departments are not required to file recipient health
insurance prior to filing Medicaid for preventive pediatric services, including
administration fees for VFC. Exceptions to this rule require that all providers
must file with a recipient’s health plan when the plan is an HMO or other
managed care plan. In addition, FQHCs and RHCs are required to file other
insurance prior to filing Medicaid as are any providers receiving a lump sum
payment for bundled services or a capitation payment from Medicaid.
A.6.2
Enrollment
The Department of Public Health is the lead agency in administering the VFC
Program. Enrollment and vaccine order forms are available through the
Immunization Division. Questions regarding enrollment should be directed to the
VFC Coordinator at (800) 469-4599.
Participation in Medicaid is not required for VFC enrollment. Participation in the
VFC Program is not required for Medicaid enrollment.
A-42 January 2011