State Health Official (SHO) Letter # 23-003

DEPARTMENT OF HEALTH & HUMAN SERVICES
Centers for Medicare & Medicaid Services
7500 Security Boulevard, Mail Stop: S2-26-12
Baltimore, Maryland 21244-1850

SHO# 23-003

June 27, 2023

RE: Mandatory Medicaid and
Children’s Health Insurance Program
Coverage of Adult Vaccinations
under the Inflation Reduction Act

Dear State Health Official:
The Centers for Medicare & Medicaid Services (CMS) is issuing this guidance on section 11405
of the Inflation Reduction Act (IRA) (Pub. L. 117-169). Beginning October 1, 2023, statutory
amendments made by section 11405 of the IRA require Medicaid and Children’s Health
Insurance Program (CHIP) coverage and payment for approved adult vaccines recommended by
the Advisory Committee on Immunization Practices (ACIP) and their administration, without
cost sharing.
Overview
CMS interprets the statutory amendments made by the IRA to require state Medicaid and CHIP
programs to cover, without cost sharing obligations, vaccines and their administration, provided
that the vaccine is approved 1 by the U.S. Food and Drug Administration (FDA) for use by adult
populations and is administered in accordance with recommendations of ACIP. 2 This coverage
requirement will go into effect on October 1, 2023, and applies in both fee-for-service and
managed care. Also, effective October 1, 2023, the statutory amendments made by the IRA
modify the requirements that states must meet in order to claim a one percentage point increase
in the federal medical assistance percentage (FMAP) for certain services described in sections
1905(a)(13)(A) and (B) and 1905(a)(4)(D) of the Social Security Act (the Act). The IRA adult
vaccination 3 coverage requirements and the IRA’s changes to the availability of this one
percentage point FMAP increase are discussed in detail beginning on page 5 of this letter.
Background
Vaccines administered to recommended populations at recommended intervals can reduce
morbidity, hospitalizations, and deaths, and save costs. Vaccines may reduce the overall burden
1

“Licensed” is the statutory term under section 351 of the Public Health Service (PHS) Act for what is commonly
referred to as approval of a biological product. When CMS uses the term “approval” to refer to FDA approval in this
document, that term includes FDA licensure under section 351 of the PHS Act.
2
To the extent possible, CMS has aligned its interpretation of section 11405 of the IRA with its interpretation of
similar language added to the Medicare statute by section 11401 of the IRA. See CMS Center for Medicare’s
“Contract Year 2023 Program Guidance Related to Inflation Reduction Act Changes to Part D Coverage of
Vaccines and Insulin,” https://www.cms.gov/files/document/irainsulinvaccinesmemo09262022.pdf.
3
In this document, CMS uses the term “vaccination” to refer both to a vaccine product and its administration.
Similarly, “immunization,” as used in the document, includes both a product and its administration.

Page 2 – State Health Official
of infections, which remain high in the United States. For example, the Centers for Disease
Control and Prevention (CDC) estimates that influenza has resulted in between 140,000 to
710,000 hospitalizations and 12,000 to 52,000 deaths annually between 2010 and 2020.4 An
estimated 150,000 individuals per year are hospitalized because of pneumococcal pneumonia. 5
In 2020, there were 5 newly reported cases of hepatitis B per 100,000 persons. 6 The human
papillomavirus (HPV) causes more than 37,000 cases of cancer each year. 7
Vaccination rates are suboptimal for all adults, regardless of health coverage, but for adults
enrolled in Medicaid, the vaccination rates for a range of vaccinations are lower than for adults
with private health insurance coverage, including influenza, tetanus, herpes zoster, hepatitis A,
hepatitis B, and HPV vaccinations. 8 Additionally, the COVID-19 public health emergency
(PHE) had a negative impact on the rate of children receiving routine childhood vaccinations.
Although child vaccination rates have rebounded since the beginning of the COVID-19 PHE,
there is still a gap in child vaccinations compared to prior years. 9
Current (Pre-IRA) Medicaid and CHIP Vaccination Coverage
As discussed below, prior to the effective date of the IRA’s amendments, Medicaid coverage of
vaccines and vaccine administration is mandatory in certain circumstances; otherwise, coverage
is at a state’s option.
States must cover, for beneficiaries under age 21 who are eligible for the Early and Periodic
Screening, Diagnostic, and Treatment (EPSDT) benefit (including beneficiaries enrolled in
Medicaid-expansion CHIPs who are eligible for EPSDT), appropriate immunizations (according
to age and health history) on the CDC/ACIP pediatric immunization schedule. In addition, other
vaccinations recommended by ACIP (including those that are recommended on the CDC/ACIP

4

Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2022. Disease
Burden of Flu. Atlanta, GA: CDC. Available
at:https://www.cdc.gov/flu/about/burden/index.html#:~:text=CDC%20estimates%20that%20flu%20has,annually%2
0between%202010%20and%202020 .
5
Centers for Disease Control and Prevention. U.S. Department of Health and Human Services, 2023: Fast Facts You
Need to Know About Pneumococcal Disease. Atlanta, GA: CDC. Available at:
https://www.cdc.gov/pneumococcal/about/facts.html#:~:text=Pneumococcal%20pneumonia%20causes%20an%20es
timated,the%20United%20States%20in%202019 .
6
Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2022. Hepatitis B
Surveillance 2020. Atlanta, GA: CDC. Available at:
https://www.cdc.gov/hepatitis/statistics/2020surveillance/hepatitis-b.htm.
7
Centers for Disease Control and Prevention. U.S. Department of Health and Human Services. 2022. How Many
Cancers are Linked with HPV Each Year. Atlanta, GA. CDC. Available at:
https://www.cdc.gov/cancer/hpv/statistics/cases.htm.
8
Estimates were based on an analysis of 2015–2018 National Health Interview Survey data. Medicaid and CHIP
Payment and Access Commission (MACPAC). March 2022 Report to Congress on Medicaid and CHIP: Chapter 2:
Vaccine Access for Adults Enrolled in Medicaid. 2022. Available at: https://www.macpac.gov/wpcontent/uploads/2022/03/Chapter-2-Vaccine-Access-for-Adults-Enrolled-in-Medicaid.pdf.
9
https://www.cdc.gov/mmwr/volumes/70/wr/mm7023a2.htm; https://www.medicaid.gov/state-resourcecenter/downloads/covid-19-medicaid-data-snapshot-07312022.pdf.

Page 3 – State Health Official
adult immunization schedule 10 for beneficiaries aged 19 or 20) and non-ACIP-recommended
vaccines and vaccine administration are covered for beneficiaries eligible for EPSDT, if the
service is determined to be medically necessary for the beneficiary based on an individualized
assessment and state medical necessity criteria. 11
Coverage of certain vaccines and vaccine administration is also mandatory for certain adult
Medicaid beneficiaries, including individuals enrolled in the Medicaid expansion group
described at section 1902(a)(10)(A)(i)(VIII) of the Act, who receive their services through an
alternative benefit plan (ABP) authorized under section 1937 of the Act. 12 In accordance with
section 1937(b)(5) of the Act and 42 CFR 440.347(a), ABPs must include coverage of the ten
essential health benefit (EHB) categories. One of the ten categories of EHB is “preventive and
wellness services and chronic disease management.” Under this category, current law and
regulations require coverage, without cost sharing, of vaccinations that have in effect a
recommendation for routine use from ACIP with respect to the individual involved. 13
Additionally, under amendments made by the American Rescue Plan Act of 2021 (ARP) (Pub.
L. 117-2), state Medicaid programs are required to cover COVID-19 vaccines and their
administration described in section 1905(a)(4)(E) of the Act, without cost sharing, for nearly all
Medicaid beneficiaries, including most eligibility groups receiving limited benefit packages
under the state plan or a section 1115 demonstration. 14 This coverage requirement generally
applies during the period beginning on March 11, 2021, and ending on the last day of the first
calendar quarter that begins one year after the last day of the COVID-19 emergency period
described in section 1135(g)(1)(B) of the Act 15 (referred to herein as the ARP coverage period).
The COVID-19 emergency period described in section 1135(g)(1)(B) of the Act ended on May
11, 2023, and therefore the last day of the ARP coverage period is September 30, 2024. 16
Aside from the COVID-19 vaccinations described in section 1905(a)(4)(E) of the Act, for all
populations in Medicaid not eligible for EPSDT or receiving coverage through an ABP, coverage
of vaccines and vaccine administration is currently optional. States can elect to cover vaccines

10

The pediatric immunization schedule identifies ACIP-recommended vaccines for those through age 18 and is
available at: https://www.cdc.gov/vaccines/schedules/downloads/child/0-18yrs-child-combined-schedule.pdf. The
adult immunization schedule identifies ACIP-recommended vaccines for those age 19 and older and is available at:
https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf.
11
Section 1905(r)(1)(B)(iii) and (5) of the Act.
12
Additionally, in accordance with 42 CFR § 440.345(a), states with ABPs must assure access to EPSDT services
for eligible individuals under 21 years of age who are receiving coverage through an ABP. This would include
vaccinations covered under EPSDT that would not otherwise be covered under the ABP.
13
42 CFR § 440.347(a)(9), 45 CFR §§ 156.110(a)(9), 156.115(a)(4), 147.130(a)(1)(ii).
14
Additional information about the beneficiaries to whom this coverage requirement applies is provided in the
COVID-19 vaccine toolkit, available at: https://www.medicaid.gov/state-resource-center/downloads/covid-19vaccine-toolkit.pdf.
15
The COVID-19 emergency period described in section 1135(g)(1)(B) of the Act is the period during which there
exists the public health emergency (PHE) declared by the Secretary of Health and Human Services pursuant to
section 319 of the PHS Act on January 31, 2020, entitled “Determination that a Public Health Emergency Exists
Nationwide as the Result of the 2019 Novel Coronavirus,” and any renewal of that declaration.
16
See https://www.hhs.gov/about/news/2023/05/11/hhs-secretary-xavier-becerra-statement-on-end-of-the-covid-19public-health-emergency.html and https://www.hhs.gov/about/news/2023/02/09/letter-us-governors-hhs-secretaryxavier-becerra-renewing-covid-19-public-health-emergency.html.

Page 4 – State Health Official
and vaccine administration for these populations under various mandatory benefits such as
inpatient hospital services (42 CFR § 440.10), outpatient hospital services (42 CFR § 440.20(a)),
physicians’ services (42 CFR § 440.50(a)), and under certain optional benefits such as services
of other licensed practitioners (42 CFR § 440.60), clinic services (42 CFR § 440.90), and
preventive services (42 CFR § 440.130(c)) depending on how the state defines the amount,
duration, and scope parameters for these benefits. States currently may also elect to cover
approved adult vaccines recommended by ACIP and their administration as described in section
1905(a)(13)(B) of the Act (and must do so if they opt to claim a one percentage point FMAP
increase for their Medicaid expenditures on certain services). As described in more detail below,
the IRA makes coverage of the services described in section 1905(a)(13)(B) mandatory for all
states, beginning October 1, 2023.
Any Medicaid cost sharing that a state elects to charge, including cost sharing for vaccines and
vaccine administration, must be nominal and comply with requirements at sections 1916 and
1916A of the Act and regulations at 42 CFR § 447.50 through 440.57. Certain populations and
services must be exempted from any Medicaid cost sharing, including pregnancy-related
services, most beneficiaries under age 18 (under age 21 at state option), and American
Indians/Alaska Natives who are currently receiving or have ever received items or services
furnished by an Indian health care provider or through referral under contract health services.
For all separate CHIP enrollees, similar to the Medicaid ARP coverage requirement, states must
cover COVID-19 vaccines and their administration, without cost sharing, in accordance with
section 2103(c)(11)(A) and (e)(2) of the Act (as added/amended by the ARP) during the ARP
coverage period. State CHIP programs must also cover ACIP-recommended vaccines and their
administration for children enrolled in a separate CHIP, with no cost-sharing, per 42 CFR §§
457.410(b)(2) and 457.520(b)(4). As of December 2022, all states that cover pregnant adults
through a separate CHIP under section 2112 of the Act voluntarily cover ACIP-recommended
vaccines and their administration for these beneficiaries, without cost-sharing. This coverage is
optional until the IRA coverage mandate takes effect on October 1, 2023.
Current (Pre-IRA) Increase in FMAP for Certain Adult Vaccinations and Other Services
Pursuant to section 1905(b) of the Act, as amended by section 4106 of the Affordable Care Act,
states that elect to cover the adult vaccinations described in section 1905(a)(13)(B) of the Act, as
well as services described in section 1905(a)(13)(A) of the Act, without cost sharing, receive a
one percentage point increase in the FMAP for their Medicaid expenditures for these services
and for their Medicaid expenditures on the tobacco cessation services for pregnant individuals
described in section 1905(a)(4)(D) of the Act. 17 This will change after October 1, 2023, under
the IRA’s amendments, as further discussed below.
Advisory Committee on Immunization Practices (ACIP)

17

Additional information is available at: https://www.medicaid.gov/federal-policy-guidance/downloads/SMD-13002.pdf#:~:text=This%20letter%20provides%20guidance%20to%20states%20on%20section,package%20%28referr
ed%20to%20as%20an%20alternative%20benefit%20plan%29 and https://www.medicaid.gov/affordable-careact/provisions/downloads/4106-faqs-clean.pdf.

Page 5 – State Health Official
ACIP is a federal advisory committee composed of medical and public health experts, as well as
a consumer representative, that provides advice and guidance to the Director of the CDC on the
most effective means to prevent vaccine preventable diseases in the United States.
Recommendations made by the ACIP are reviewed by the CDC Director and, if adopted, are
published as official CDC recommendations in the Morbidity and Mortality Weekly Report. 18 19
ACIP also develops written recommendations—subject to adoption by the CDC Director—for
the routine use 20 of vaccines for both pediatric and adult populations for inclusion on the
CDC/ACIP immunization schedules. To inform its advice to the CDC Director, ACIP considers
disease epidemiology, burden of disease, vaccine efficacy and effectiveness, vaccine safety, the
quality of evidence reviewed, economic analyses, and implementation issues.
The ACIP makes vaccination recommendations for different groups of people.
Recommendations are by age group (as shown in Table 1 of the annual adult immunization
schedule) or by risk group (some of which are shown in Table 2 of the annual adult
immunization schedule), including risk due to underlying condition, occupation, or travel. 21
Some of ACIP’s recommendations are not considered routine (that is, are not included on the
adult or pediatric immunization schedules) but reflect the same considerations as vaccines
included on the immunization schedules.
Most of ACIP’s recommendations, including those both on and off the adult immunization
schedule as described above, are for vaccinations for everyone (without contraindication) in a
designated age or risk group (standard recommendations). ACIP also makes recommendations
for shared clinical decision-making, in which the health care provider and the patient or
parent/guardian consider whether or not to vaccinate. These other recommendations are not
always included on the annual immunization schedules. Vaccination recommendations for
shared clinical decision-making that are listed on the CDC/ACIP immunization schedules are
considered to be for routine use. However, when these recommendations are not included on the
CDC/ACIP immunization schedules, they would not be considered to be for routine use. The key
distinction between standard recommendations and shared clinical decision-making
recommendations relates to whether there should be a default decision to vaccinate. For standard
recommendations, the default decision should be to vaccinate the patient based on age group or
other indication, unless contraindicated. For shared clinical decision-making recommendations,
there is no default—the decision about whether or not to vaccinate may be informed by the best
available evidence of who may benefit from vaccination; the individual’s characteristics, values,

18

The ACIP holds three regular meetings each year, in addition to emergency sessions. For more information, see:
https://www.cdc.gov/vaccines/acip/committee/role-vaccine-recommendations.html.
19
ACIP also has a statutorily defined role with respect to the Vaccines for Children (VFC) program. For more
information, please see: https://www.cdc.gov/vaccines/programs/vfc/index.html;
https://www.cdc.gov/vaccines/programs/vfc/providers/resolutions.html.
20
As defined for purposes of the vaccination coverage that must be included in Medicaid ABP coverage, ACIP
recommendations for “routine use” are those that are listed on the CDC/ACIP immunization schedules. See 45 CFR
147.130(a)(1)(ii). References to “routine” vaccinations or “routine” ACIP recommendations in this SHO letter have
that same meaning.
21
https://www.cdc.gov/vaccines/schedules/hcp/imz/adult.html

Page 6 – State Health Official
and preferences; the health care provider’s clinical discretion; and the characteristics of the
vaccine being considered. 22
Section 11405 of the IRA – New Mandatory Medicaid and CHIP Adult Vaccination
Coverage
Section 11405(a)(1) of the IRA amended section 1902(a)(10)(A) of the Act to include, effective
October 1, 2023, items and services described in section 1905(a)(13)(B) in the list of Medicaid
benefits that must be available to categorically needy individuals (subject to the coverage
limitations for certain eligibility groups in the language following section 1902(a)(10)(G)). This
same provision of the IRA amended section 1902(a)(10)(C)(iv) of the Act to require, also
effective October 1, 2023, Medicaid coverage of the items and services described in section
1905(a)(13)(B) of the Act for certain medically needy beneficiaries. 23 Section 11405(b)(1) of
the IRA added mandatory coverage of the services described in section 1905(a)(13)(B) for CHIP
enrollees at section 2103(c)(12) of the Act. Section 11405 also amended sections 1916(a)(2),
1916(b)(2), 1916A(b)(3)(B), and 2103(e)(2) of the Act to specify that states cannot impose cost
sharing with respect to the vaccination coverage that is described in sections 1905(a)(13)(B) and
2103(c)(12) of the Act. Under these amendments, beginning October 1, 2023, state Medicaid
and CHIP programs must cover approved adult vaccines recommended by ACIP, and their
administration, without cost sharing; these requirements apply in both fee-for-service and
managed care.
Section 1905(a)(13)(B) of the Act
CMS interprets section 1905(a)(13)(B) of the Act as follows, including for purposes of the IRA’s
amendments requiring state Medicaid and CHIP programs to cover the vaccinations described in
that section, without cost sharing obligations. Section 1905(a)(13)(B) describes the following
services: “with respect to an adult individual, approved vaccines recommended by the [ACIP] …
and their administration[.]” CMS interprets this language to describe vaccines that are approved
by the FDA for use by adult populations and administered in accordance with recommendations
of ACIP. CMS does not interpret “approved” to include vaccines that FDA has authorized for
use under emergency use authorization, but has not approved. The coverage described in section
1905(a)(13)(B) is both of the vaccines themselves (i.e., the vaccine doses), and their
administration.
22

All ACIP recommendations by vaccine are available here: https://www.cdc.gov/vaccines/hcp/aciprecs/index.html.
23
States that cover the medically needy must choose their medically needy benefit package. If a state that covers the
medically needy elects to make services in institutions for mental diseases and/or intermediate care facilities for the
developmentally disabled available to any medically needy group, the state’s medically needy benefit package for
all medically needy groups must include at least the services described in one of two options identified in section
1902(a)(10)(C)(iv) of the Act. Prior to the IRA’s enactment, one of these options was “the care and services listed in
paragraphs (1) through (5) and (17) of section 1905(a),” and section 11405(a)(1) of the IRA amended section
1902(a)(10)(C)(iv) to add section 1905(a)(13)(B) to this particular option. The other option in section
1902(a)(10)(C)(iv) is “the care and services listed in any 7 of the paragraphs numbered (1) through (24) of [section
1905(a)].” A state that elects the latter option for its medically needy benefit package could, but would not be
required to, include the items and services described in section 1905(a)(13)(B) in its medically needy benefit
package.

Page 7 – State Health Official
Additionally, CMS interprets an “adult individual,” for purposes of section 1905(a)(13)(B) of the
Act, to refer to beneficiaries 19 years of age or older, which is consistent with the adult
immunization schedule that identifies ACIP-recommended vaccines for those age 19 and older.
This also aligns with how CMS has historically interpreted section 1905(a)(13)(B) for purposes
of the one percentage point FMAP increase established by section 4106 of the Affordable Care
Act, 24 and is also aligned with the age at which a CHIP beneficiary is no longer a child for
purposes of eligibility (as defined at section 2110(c)(1) of the Act).
As noted earlier, there are multiple categories of ACIP recommendations for adult vaccines,
including recommendations described on the CDC/ACIP adult immunization schedule (as
determined by age and risk and recommendations for shared clinical decision-making), and
recommendations based on risk due to health condition, occupation, and travel. Beginning
October 1, 2023,25 CMS interprets the reference to ACIP recommendations in section
1905(a)(13)(B) of the Act to include any category of ACIP recommendations. The IRA
coverage requirement is therefore not limited to vaccines that ACIP includes on the
immunization schedules or recommends for routine use. 26 States should establish processes to
monitor and implement any new or updated ACIP recommendations.
As previously explained, state Medicaid and CHIP programs are currently required to cover,
without cost sharing, the COVID-19 vaccines and their administration described in section
1905(a)(4)(E) of the Act (for Medicaid) and 2103(c)(11)(A) of the Act (for CHIP) during the
ARP coverage period, which will end on September 30, 2024. At the conclusion of the ARP
coverage period, COVID-19 vaccinations that are approved by the FDA for use by adult
populations and that are administered in accordance with any category of ACIP
recommendations would be covered, without cost sharing, as part of the IRA-required adult
vaccination coverage described in sections 1905(a)(13)(B) and 2103(c)(12) of the Act.
However, states are currently required to cover COVID-19 vaccinations for a broader range of
Medicaid eligibility groups than will receive the mandatory adult vaccination coverage under the
IRA. For example, the ARP COVID-19 vaccination coverage requirements apply to certain
limited-benefit eligibility groups, such as individuals eligible for family planning benefits, that
will not receive the mandatory adult vaccination coverage under the IRA. This means that
individuals in certain Medicaid eligibility groups that currently receive coverage of COVID-19
vaccinations described in section 1905(a)(4)(E) of the Act will not receive coverage for these
services as part of the IRA-required adult vaccination coverage after the ARP coverage period
ends.27

24

Questions & Answers on ACA Section 4106 Improving Access to Preventive Services for Eligible Adults in
Medicaid: https://www.medicaid.gov/affordable-care-act/provisions/downloads/4106-faqs-clean.pdf.
25
See footnote 28.
26
As noted earlier, to the extent possible, CMS has aligned its interpretation of section 11405 of the IRA with its
interpretation of similar language added to the Medicare statute by section 11401 of the IRA. See
https://www.cms.gov/files/document/irainsulinvaccinesmemo09262022.pdf.
27
Coverage of COVID-19 vaccinations described in section 1905(a)(4)(E) is required for nearly all Medicaid
beneficiaries, including most eligibility groups receiving limited benefit packages under the state plan or a section
1115 demonstration, while the IRA-required adult vaccination coverage described in section 1905(a)(13)(B) is

Page 8 – State Health Official
Increased FMAP
As explained earlier, states that currently provide Medicaid coverage for services described in
sections 1905(a)(13)(A) and (B) of the Act, without cost sharing, receive a one percentage point
increase in their FMAP for their Medicaid expenditures for these services, as well as for their
Medicaid expenditures for the tobacco cessation services for pregnant individuals described in
section 1905(a)(4)(D) of the Act. Section 11405(a)(3) of the IRA amended section 1905(b) of
the Act to specify that states that were covering, as of the date of enactment of the IRA (August
16, 2022), vaccinations described in section 1905(a)(13)(B) without cost sharing will receive a
one percentage point increase in the FMAP for their Medicaid expenditures for these vaccination
services for the first eight fiscal quarters that begin on or after October 1, 2023. 28 At the
conclusion of the eight fiscal quarters (September 30, 2025), these states’ Medicaid expenditures
for vaccines and vaccine administration described in section 1905(a)(13)(B) of the Act will be
matched at the applicable regular FMAP.
Effective October 1, 2023, states that opt to cover preventive services described in section
1905(a)(13)(A) of the Act without cost sharing will receive a one percentage point FMAP
increase in their Medicaid expenditures for those services and for the tobacco cessation services
for pregnant individuals described in section 1905(a)(4)(D) of the Act, and can continue to
receive that FMAP increase even after September 30, 2025.
Provider Qualifications for Vaccinations
States generally have broad flexibility to establish Medicaid provider qualifications (subject to
the Medicaid free choice of provider requirement), including qualifications for providers that
administer vaccines. States may have licensure and scope of practice laws and regulations,
and/or other policies governing who is authorized to administer vaccines. CMS encourages
states to review current state laws and policies to ensure that a broad array of providers who
work in diverse settings (e.g., physician offices, clinics, pharmacies, hospitals) are authorized to
administer vaccines as this could help to maximize beneficiaries’ access to vaccines.

mandatory for all full-benefit categorically needy beneficiaries and (depending on the state’s decisions about its
Medicaid benefit packages) certain medically needy beneficiaries. Individuals in nearly all Medicaid eligibility
groups are eligible for the ARP COVID-19 vaccination coverage described in section 1905(a)(4)(E) of the Act,
including the following limited-benefit eligibility groups: individuals eligible only for family planning benefits;
individuals eligible for tuberculosis-related benefits; and section 1115(a)(2) expenditure authority limited-benefit
groups.
28
In previous guidance about the one percentage point FMAP increase, CMS referenced the CDC/ACIP adult
immunization schedule and did not explain whether states should cover approved adult vaccines administered
according to the full range of ACIP recommendations (including vaccines not on the CDC/ACIP adult immunization
schedule). See https://www.medicaid.gov/federal-policy-guidance/downloads/smd-13-002.pdf. Therefore, states
can continue to receive the one percentage point FMAP increase after October 1, 2023, if, on August 16, 2022, they
were providing the vaccination coverage that, under CMS’s guidance as of August 16, 2022, permitted them to
claim the one percentage point FMAP increase. Beginning on October 1, 2023, all states, including those who keep
receiving the one percentage point FMAP increase after that date, will have to provide coverage in alignment with
this guidance (i.e., the full range of ACIP recommendations).

Page 9 – State Health Official
Although states generally have broad flexibility to set Medicaid provider qualifications, states
are reminded that HHS Public Readiness and Emergency Preparedness (PREP) Act declarations
might identify certain practitioners as “covered persons” authorized to administer certain
vaccines, such as those for COVID-19 and mpox. 29 These HHS PREP Act authorizations
preempt conflicting state scope of practice or licensure laws and thus have Medicaid payment
implications, as a result of the Medicaid free choice of provider requirement. Specifically, when
a state covers a vaccination for a beneficiary, and a practitioner (such as a pharmacist or
pharmacy technician) is authorized to administer that vaccine under an HHS PREP Act
declaration, the state Medicaid program would be required to provide a pathway to paying that
practitioner for the covered vaccine administration, when provided in accordance with the
provisions of the HHS PREP Act declaration. States still must meet all other applicable federal
requirements for covering the applicable benefit, such as reimbursing only those providers that
are enrolled as Medicaid providers and covering vaccinations only for eligible individuals.
Payment for Vaccinations
Within the parameters of section 1902(a)(30)(A) of the Act, states have flexibility to set
Medicaid payment rates for vaccines and vaccine administration. To help improve access to
these services for Medicaid beneficiaries, CMS encourages states to consider setting payment
rates for vaccines at actual acquisition cost and an adequate professional fee for administration to
incentivize access to and availability of vaccines.
If states utilize a managed care delivery system to provide coverage for vaccines and vaccine
administration, states should carefully analyze and assess their current managed care contracts
and capitation rates for any necessary revisions or amendments in light of this guidance. As with
all covered benefits in a Medicaid managed care plan contract, capitation rates must be
developed to include all reasonable, appropriate, and attainable costs that are required under the
terms of the contract, as specified in 42 CFR § 438.4(a). Payment to healthcare providers for
vaccines and vaccine administration may be specified by the state in a Medicaid managed care
plan’s contract, subject to the CMS approval requirements for state directed payments in 42 CFR
§ 438.6(c), 30 or may be determined by each managed care plan.
For states that use a managed care delivery system for their separate CHIPs, payment rates from
the state to the managed care entity must be based on public or private rates for comparable
populations and comparable services, consistent with actuarially sound principles, and are
subject to the rate development standards at 42 CFR § 457.1203(a). In addition, 42 CFR §
457.1203(b) allows for flexibility in setting higher rates if such rates are necessary to ensure

29

For more information on the Medicaid implications of the HHS COVID-19 PREP Act declaration, see:
https://www.medicaid.gov/state-resource-center/downloads/covid-19-vaccine-toolkit.pdf; and for more information
on the Medicaid implications of the HHS PREP Act declaration for smallpox, monkeypox, and orthopoxvirus
medical countermeasures, see: https://www.medicaid.gov/resources-forstates/downloads/covid19allstatecall12062022.pdf and https://www.hhs.gov/sites/default/files/monkeypox-faqpharmacy-partners.pdf.
30
For more information on state directed payments, please visit: https://www.medicaid.gov/medicaid/managedcare/guidance/state-directed-payments/index.html.

Page 10 – State Health Official
sufficient provider participation or provider access or to enroll providers who demonstrate
exceptional efficiency or quality in the provision of services.
State Plan Amendments (SPAs)
States that have not already included an attestation in the Medicaid state plan stating that they
cover the vaccines and vaccine administration described in section 1905(a)(13)(B) of the Act
must submit a coverage SPA with an effective date of no later than October 1, 2023. On the
supplement to attachments 3.1-A and 3.1-B (if applicable) coverage pages for the preventive
services benefit, states should attest to coverage under the Medicaid state plan of vaccines and
vaccine administration described in section 1905(a)(13)(B) of the Act. States should provide an
additional assurance stating that they have a method to ensure that, as changes are made to ACIP
recommendations, they will update their coverage and billing codes to comply with those
revisions. States that do not have an approved payment methodology for these services must also
submit a payment SPA with an effective date of no later than October 1, 2023. As with any SPA
submission, CMS expects states to comply with all applicable federal Medicaid SPA
requirements.
States should generally not need to submit a Medicaid cost sharing SPA to attest to compliance
with these requirements because standard language in the cost-sharing state plan templates
already specifies that the state is compliant with requirements at sections 1916 and 1916A of the
Act, which were amended by section 11405 of the IRA to prohibit cost sharing for the vaccines
described in section 1905(a)(13)(B) and administration of such vaccines.
States will also need to submit a CHIP SPA pursuant to the CMS requirements at 42 CFR §
457.60(a). States should indicate that they are covering, without cost sharing, all approved adult
vaccines that are administered in accordance with ACIP recommendations, per sections
2103(c)(12) and 2103(e)(2) of the Act. More information will be forthcoming about the CHIP
SPAs.
Conclusion
Mandatory coverage of all approved ACIP-recommended adult vaccinations, without costsharing, will improve access to vaccinations for adult Medicaid and CHIP beneficiaries. This
change also has the potential to prevent hospitalizations and deaths and reduce costs associated
with preventable infections. Please submit any questions about this guidance to Kirsten Jensen,
Director of the Division of Benefits and Coverage, at [email protected].
Sincerely,

Daniel Tsai
Deputy Administrator and Director