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Centers for Medicare & Medicaid Services
Overview of Vaccine Coverage
December 2025
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Medicaid and CHIP
•Coverage of vaccines is anchored to ACIP recommendations, and the
adult/pediatric vaccine schedules, which is based on those recommendations.
•State Medicaid and Children’s Health Insurance Programs (CHIP) are required to
cover all vaccines recommended by CDC/ACIP that are included on the
adult/pediatric immunization schedules without cost sharing for most
beneficiaries, including children and adults.*
•Recommendations included on the pediatric/adult immunization schedules that
refer to shared clinical decision making, also known as individual -based decision
making, are mandatorily covered in both Medicaid and CHIP .
•The Vaccines For Children (VFC) program is a vaccine distribution program
overseen by CDC that provides federally purchased vaccines to children through
age 18 who are either enrolled in Medicaid, uninsured, underinsured, or
American Indian/Alaska Native. Each state runs a VFC program according to CDC
guidelines, typically through the state health department, and makes state
coverage decisions.
* Mandatory Medicaid vaccination coverage varies between adults and children, see the coverage chart on slide 4 for more info rmation.
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Medicaid and CHIP (continued)
•States have flexibility to determine Medicaid/CHIP coverage beyond mandatory
coverage anchored to the ACIP/CDC recommendations and the pediatric and adult
immunization schedules. Therefore, any recommendation that is not on the pediatric
vaccine schedule or any recommendation that narrows the criteria will lead to variable
coverage across state Medicaid & CHIP programs.
•In Medicaid, through Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)
requirements, coverage for individuals up to age 21 could include additional
vaccinations beyond what is included on the vaccine schedule based on the state’s
medical necessity criteria. In CHIP , states have the flexibility to choose to cover vaccines
beyond what is included in the immunization schedule.
•If states opt to provide expanded vaccine coverage, they will receive federal match for
the full scope of coverage. States may not need approval from CMS to provide coverage
beyond the ACIP recommendation as that level of detail is not required in the Medicaid
& CHIP state plans.
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Medicaid and CHIP (continued)
4Population Is coverage of vaccines and their administration mandatory?
Adult Medicaid Full Coverage/Full
Benefit Enrollees YES, for all categories of ACIP recommendations .
Adults Enrolled in Alternative
Benefit Plans (typically adults
enrolled in the Medicaid expansion)YES, for all routine ACIP recommendations (those on the adult/pediatric immunization
schedule) . States that align ABP coverage with state plan coverage will need to cover all
ACIP recommended vaccinations per the IRA coverage requirements.
Child Medicaid Full Coverage/Full
Benefit Enrollees Aged 18 and
Younger YES, for all vaccines on the CDC/ACIP pediatric schedule and those vaccinations determined
to be medically necessary as established by the state. Therefore, any recommendation that
is not on the pediatric vaccine schedule or any recommendation that narrows the criteria
will lead to variable coverage across state Medicaid & CHIP programs.
Child Medicaid Full Coverage/Full
Benefit Enrollees Aged 19 and OlderYES, for all categories of ACIP recommendations.
CHIP Enrollees YES, for all categories of ACIP recommendations .
Private / Employer Sponsored Plans
•Non -grandfathered employer -sponsored plans and non -grandfathered group and
individual health insurance coverage are required to cover all ACIP -recommended
vaccines for routine use without cost sharing.
oThis includes recommended vaccines on the pediatric vaccine schedule.
•With respect to employer -sponsored and individual health insurance coverage (as
opposed to self -insured employer -sponsored plans governed by ERISA), states may
impose benefit mandates, including vaccination mandates, that are more expansive
than Federal requirements.
•Plans and issuers are required to continue to cover the vaccine in a manner
consistent with the current recommendation for the duration of a plan or policy year
before the applicable plan or policy year of the new recommendation, unless doing so
would pose a significant safety concern.
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