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    OpenPayerPolicy UpdatesAdministrative/Operational PolicyUtah Medicaid Immunization Policy Update | OpenPay…
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    CurrentUtah MedicaidPolicy 25-0002

    Utah Medicaid State Agency Organization and Consultation Requirements

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    This policy governs Utah Medicaid’s single-state agency organization, pediatric immunization program responsibilities, managed care advisory consultation, and ongoing consultation with Tribal governments, Indian Health Service, and Urban Indian organizations.

    Policy Summary
    PayerUtah Medicaid
    PolicyState Agency Organization and Consultation Requirements
    Policy CodePolicy 25-0002
    Change TypeNo material change
    Effective DateJul 1, 2025
    Next Review DateN/A
    Key ActionProgram-registered providers must administer medically appropriate vaccines to vaccine-eligible children according to the Advisory Committee on Immunization Practices schedule and may not charge for the vaccines.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    42 CFRFederal provisions cited
    8Tribal governments represented
    MonthlyAdvisory board meetings
    3Area offices represented

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    No charge
    Vaccine charge

    Pediatric Immunization Program Requirements

    Pediatric immunization program requirements

    The pediatric immunization program provides vaccines to program-eligible children when all of the following requirements are met:

    ALL of the following

    • The child is vaccine-eligible under sections 1928(b) and 1928(h) of the Social Security Act.
    • The vaccines are medically appropriate and provided according to the schedule developed by the Advisory Committee on Immunization Practices.
    • The vaccines are provided without charge, and the child is not denied vaccines because of an inability to pay an administration fee.
    • Vaccines are administered by a program-registered provider, and the provider does not charge more for vaccine administration than the regional maximum established by the Secretary.

    Administration Fee Limits

    Maximum Vaccine Administration Fee
    Maximum administration feeRegional maximum established by the Secretary
    Provider billing limitA program-registered provider may not charge more for vaccine administration than the regional maximum.
    Payment protectionA vaccine-eligible child may not be denied vaccines because of inability to pay an administration fee.

    Provider Responsibilities

    Note

    Provide Medically Appropriate Vaccines

    Administer each vaccine-eligible child medically appropriate vaccines according to the schedule developed by the Advisory Committee on Immunization Practices. Vaccines must be provided without charge to the child.

    Documentation Required

    Determine Vaccine Eligibility

    Determine whether each child is vaccine-eligible in accordance with sections 1928(b) and 1928(h) of the Social Security Act before providing services under the program.

    Billing Rule

    Key Program and Consultation Terms

    State Medical Care Advisory Committee
    RoleAdvises the Medicaid agency director on health and medical care services.
    Regulatory basisEstablished in accordance with and meeting all requirements of 42 CFR 431.12.
    Managed care consultationThe State consults with the committee on the review of marketing materials in accordance with 42 CFR 438.104(c).
    Program-Registered Provider
    DefinitionA provider participating in the State pediatric immunization program and authorized to receive and administer vaccines under the program.
    Program roleProvides medically appropriate vaccines to vaccine-eligible children according to the schedule developed by the Advisory Committee on Immunization Practices.
    Policy Summary
    PayerUtah Medicaid
    PolicyState Agency Organization and Consultation Requirements
    Policy CodePolicy 25-0002
    Change TypeNo material change
    Effective DateJul 1, 2025
    Next Review DateN/A
    Key ActionProgram-registered providers must administer medically appropriate vaccines to vaccine-eligible children according to the Advisory Committee on Immunization Practices schedule and may not charge for the vaccines.
    SourceLink
    On This Page
    Pediatric Immunization Program RequirementsAdministration Fee LimitsProvider ResponsibilitiesKey Program and Consultation Terms

    Apply Fee Limits and Payment Protections

    Follow the administration-fee limits and payment protections established for the pediatric immunization program.

    • Do not charge more for vaccine administration than the regional maximum established by the Secretary.
    • The State will inform program-registered providers of the maximum administration fee.
    • Do not deny vaccines to an eligible child because the child or family cannot pay the administration fee.
    Note

    Support Language- and Culturally Appropriate Access

    Support access for vaccine-eligible children whose parents have limited ability to speak English by providing communication in the language and cultural context most appropriate for the population served.

    • Coordinate with or serve through program-registered providers able to communicate with the affected vaccine-eligible population in an appropriate language and cultural context.
    Note

    Participate in the Pediatric Immunization Provider Network

    Participate in the pediatric immunization provider network and support outreach so vaccines are available through a variety of qualified providers and settings.

    • Administer vaccines in multiple settings, including private healthcare providers, providers receiving funds under Title V of the Indian Health Care Improvement Act, and health programs or facilities operated by Indian tribes.
    • Maintain participation as a program-registered provider and support the State’s list of program-registered providers.
    • Do not require or impose additional qualifications or conditions for provider registration beyond those specified by the program, except as authorized under section 1915(b) of the Social Security Act or permitted by the Secretary to prevent fraud or abuse.
    Program requirementThe State maintains a list of providers registered in the pediatric immunization program.
    Utah Indian Health Advisory Board (UIHAB)
    Tribal representationAppointed health representatives from all eight Utah Tribal governments serve on the board.
    Participating organizationsThe board includes Indian Health Service and Urban Indian Organization representatives in Utah.
    Area-office representationThree Indian health services area offices serving American Indian and Alaska Native people in Utah are represented: Albuquerque, Navajo, and Phoenix.
    Meeting frequencyThe board meets monthly and is facilitated by the Indian Health Liaison for the single state agency.
    Advisory topicsStanding agenda items include Medicaid, CHIP, state plan amendments, and rulemaking.
    Tribal Consultation
    PurposeAn established process for the single state agency to seek regular, ongoing advice on Medicaid and CHIP matters that directly affect Indian health programs and Urban Indian organizations.
    ParticipantsConsultation involves Utah Tribal governments, Indian Health Service, and the Urban Indian Organization.
    Initial consultation stepMedicaid presents state plan amendments and waivers to the Utah Indian Health Advisory Board as the initial step in the consultation process.
    Further consultationIf the board or an individual Tribe requests additional consultation, a separate meeting is scheduled for the specific issue.
    Consultation frameworkThe model uses the Utah federally recognized tribal consultation policy, the Utah Indian Health Advisory Board, and the Indian Health Liaison or Health Policy Consultant for the single state agency.