Use of vaccines for children (VFC) deputization to extend access to VFC vaccines for underinsured children: Q&A fact sheet [Dec. 2012]

Use of Vaccines for Children (VFC) Deputization to Extend Access to VFC Vaccines for Underinsured Children Q&A Fact Sheet
Centers for Disease Control (CDC) Background: Children from birth through 18 years of age who meet at least one of the following criteria are eligible to receive Vaccine for Children (VFC) vaccine at any VFC provider site: 1) Medicaid eligible, 2) Uninsured, 3) American Indian or Alaska Native. Underinsured children are also eligible for VFC vaccine, but only when administered at a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC). Currently, less than ten percent nationally of VFC provider sites are FQHCs or RHCs, both of which, for reasons of geography, have limited access and capacity to serve this population. The CDC reports that historically, in more than 20 states, including Georgia, FQHCs and RHCs have extended access to VFC vaccines for underinsured children through deputization arrangements (sometimes referred to as "delegation of authority") with local health departments (LHD) and, in some cases, private-sector VFC-enrolled providers.
Underinsured is defined as: A person who has health insurance, but the coverage does not include vaccines or a person whose insurance covers only selected vaccines or whose insurance caps vaccine coverage at a certain dollar amount. Children who are underinsured for selected vaccines or who have exceeded their capped amount are VFC-eligible for non-covered vaccines only at a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) or under an approved deputization agreement. The Patient Protection and Affordable Care Act (ACA) require that non-grandfathered private health plans provide coverage for routine ACIP-recommended immunizations without cost-sharing. However, health plans that currently do not offer vaccinations retain their "grandfathered" status until they make a significant change in coverage. Thus, it is likely to take several years before all grandfathered plans lose this status and this form of underinsurance is completely addressed.
Data from CDC's 2008 National Immunization Survey shows that 11% of young children (0-6 years) and 20% of teens (7-18 years) are not fully insured for vaccines. Until underinsurance among children is eliminated, extending VFC authority to other VFC providers serves as a safety net ensuring that access to VFC vaccine for eligible underinsured children will not be a barrier to vaccination.
Georgia Facts: In the past, Georgia FQHCs and RHCs "delegated" the authority to vaccinate underinsured children to all LHDs and private sector VFC-enrolled providers. These delegation agreements will no longer be valid after December 31, 2012. In order to
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assure that underinsured children don't miss opportunities for recommended and needed vaccinations, deputization will extend the VFC authority of FQHCs and RHCs to select LHDs and private sector VFC-enrolled providers beginning in 2013. In September 2012, a list of all LHDs and private sector VFC-enrolled providers to be recommended for deputization was forwarded to CDC for approval. The Georgia Immunization Program (GIP) recommended that all 21 LHDs and 10 private sector providers be deputized. CDC approval to move forward with this deputization was granted on September 25, 2012.
Deputization is not replacing the "medical home" for children but is intended to help guarantee access to immunizations services for children who might not otherwise be vaccinated. GIP recognizes that care within a medical home is a best practice to meet the needs of Georgia children. Unfortunately, not all children have a medical home and not all providers offer vaccinations in their practice. Children who lack access to care will be exposed to vaccine-preventable diseases, may be excluded from school, and will place others at risk for vaccine-preventable disease.
It is an ongoing requirement that all VFC providers screen each child for VFC eligibility at every visit, including determination of underinsurance status. This eligibility must be documented in the child's permanent record. All VFC providers currently report monthly the number of children screened for eligibility by eligibility status. GIP must report these numbers to the CDC by provider type, eligibility status and doses administered. This data collection practice will not change with deputization.
Each provider is accountable for their vaccine practices to GIP. GIP is, accountable to the CDC for monitoring and reporting these practices. The CDC has the ultimate authority over the VFC program.
In order to deputize or be deputized, each FQHC, RHC and deputized VFC Provider must have a current VFC Provider Enrollment on file with GIP and must re-enroll in the VFC program annually. The CDC has provided a template agreement, which is referred to as a Memorandum of Understanding (MOU) to be used in the deputizing process. The MOU will remain in effect unless there are material changes in the status of the FQHC/RHC or LHD. The FQHC/RHC may also withdraw granting authority with 90 days written notice to GIP and to the deputized VFC Provider. Deputization guidance from the CDC applies to FQHC "Look Alikes." These clinics are certified by the Centers for Medicare and Medicaid Services (CMS) to serve underinsured children and can sign a deputizing MOU.
The deputization process is not complicated and includes these steps: 1. GIP submits to CDC for approval by October 1st of each year the list of VFC Providers to be deputized along with the proposed MOU.
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2. GIP sends the approved MOU to the list of FQHCs and RHCs, along with this notice, for their agreement to deputize all VFC providers listed in attachment A of their MOU.
3. The FQHC or RHC signs the MOU and returns the signed document to GIP, noting their agreement to deputize all VFC providers listed in attachment A of their MOU.
4. GIP sends the signed MOU to the list of selected VFC providers, along with this letter and notice of their selection to be deputized by the FQHC or RHC listed in their MOU.
5. The LHD signs the MOU and returns the signed document to GIP, noting their agreement to be deputized.
6. GIP signs the submitted MOU and sends the original MOU to the deputizing FQHC or RHC, a copy to the deputized VFC provider and keeps a copy on file.
7. GIP notifies CDC of executed MOUs by February 28, 2013. 8. If a material change in the FQHC, RHC or deputized VFC provider occurs (e.g.,
ownership or management changes, loss of Medicaid or Medicare status, cease operations, etc.), the MOU is terminated or may be re-signed, depending on the circumstances. 9. The FQHC or the RHC may, with 90 days written notice to GIP and to the deputized VFC provider(s), withdraw their granting authority. 10. GIP reports annually to the FQHC or RHC and CDC the number of children immunized at each deputized VFC provider under each MOU.
It is the position of the CDC that extending access to VFC vaccine through deputization may expose the deputizing FQHC/RHC to liability. The National Vaccine Injury Compensation Program (NVICP) greatly reduces the legal liabilities involved in administering most vaccines. The NVICP is a no-fault alternative to the traditional tort system for resolving vaccine injury claims that provides compensation to people found to be injured by certain vaccines. Generally, persons with claims of vaccine-related injuries or deaths resulting from covered vaccines must first exhaust their remedies under the NVICP before they can pursue alternative legal actions against vaccine administrators. In addition, for certain vaccines to prevent diseases, health conditions, and threats that constitute or threaten a public health emergency and that are not covered by NVICP, the Public Readiness and Preparedness Act of 2005 (PREP Act) may provide liability protection to providers administering such vaccines, and the Countermeasures Injury Compensation Program established by the PREP Act may provide compensation to eligible individuals who are injured by these vaccines.
Q&A: Q. What is deputization? A. Deputization is the process of a Federally Qualified Health Center (FQHC) or a Rural Health Clinic (RHC) extending to a Local Health Department (LHD) the VFC authority to vaccinate underinsured (0 through 18 years) children.
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Q. Why deputize VFC-enrolled providers? A. The federal government has directed the CDC to require all immunization program grantees (e.g., The Georgia Immunization Program, GIP) to seek formal deputization agreements between FQHCs, RHCs and LHDs or private sector VFC-enrolled providers, in the form of an MOU, to help assure immunization services for underinsured children. Nationally, 20% of all providers are FQHCs/RHCs and their capacity to see all underinsured children is limited. By deputizing VFC-enrolled providers, access to immunization services for these children is improved.
Q. Georgia VFC providers were `delegated' this authority previously. Why can't these agreements continue? A. The Centers for Medicare and Medicaid Services (CMS) via Health and Human Services (HHS) directed the CDC to formalize this process across all immunization programs in the country. The prior "delegation" will no longer be valid and new "deputization" MOUs need to be signed.
Q. Will deputizing LHDs adversely impact the "medical home" concept? A. No. Deputizing LHDs is a tool to maintain access to immunization services only. GIP and the LHD both support and work to encourage families to seek out and establish medical homes for all care. Unfortunately, many children do not have a medical home and many providers do not offer immunization services in their practices. In a few Georgia counties, the LHD is the only provider of immunizations.
Q. Is the FQHC/RHC required to monitor the deputized VFC provider's vaccine practices? A. No. GIP is accountable for monitoring all VFC provider immunization practices. The MOU requires all deputized VFC providers report to GIP, monthly, the numbers of underinsured children immunized by vaccine antigen. Monthly reporting of vaccine use is required from all VFC providers.
Q. Can non-FQHC/RHC clinics immunize underinsured children? A. Yes. In Georgia non-FQHC/RHC deputized clinics may immunize an underinsured child using 317-DA funded vaccine supply. This funding is limited, thus limiting the amount of vaccine available for children vaccinated in non-FQHC/RHC or deputized clinical settings.
Q. Isn't the Affordable Care Act supposed to decrease the numbers of underinsured children? A. Yes. However, the CDC projects this will take several years since grandfathered plans must make significant changes to their coverage before they are required to offer coverage for all ACIP recommended vaccines to children.
Q. Why don't FQHCs/RHCs see all underinsured children?
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A. Most FQHCs/RHCs offer immunization services to established patients. They rarely see non-established patients on a walk-in basis. Many underinsured children do not have medical homes and may not be able to access a FQHC/RHC. Q. Does deputization require seeing underinsured children on a walk-in basis? A. Yes. The deputized provider must offer walk-in immunization services to the underinsured child during hours of operation. Q. When can the MOU be signed? A. Georgia will send the approved MOU to the FQHCs, RHCs and VFC providers for execution upon final approval. Q. How do we know which FQHCs and RHCs will deputize a VFC provider? A. GIP has provided an "Intent to Deputize" sheet to all FQHCs and RHCs with this communication. A list of those FQHCs or RHCs who are willing to deputize one or more VFC providers will be sent a copy of the approved MOU for signature with a list of selected providers in their district. This process will facilitate continuing partnerships between the FQHC, RHC, VFC providers and GIP. Q. What do VFC providers do once they have a deputizing FQHC or RHC? A. VFC provider will sign the CDC approved MOU (GIP will send out the final MOU following CDC approval). VFC providers will send their signed copy of the MOU to GIP. GIP signs and forwards the original signed MOU to the FQHC or RHC, a signed copy to the LHD and keeps a copy on file. This process will occur during mid to late January. Q. What if the VFC provider does not want to be deputized? A. VFC providers are asked to notify Sheila Lovett, Deputy Immunization Program Director at 404-657-9635 or szlovett@dhr.state.ga.us of this decision no later than February 15, 2013.
Deputization Q&A Fact: December 2012
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