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A summary of presentations from the weekly Summit partner webinars

November 6, 2025 – Payment Challenges in the New Immunization Environment

This webinar discusses payment challenges with a discussion that followed.

Speakers:

Chelsea Cipriano, Managing Director, Common Health Coalition (CNC)
Mitchell Finkel, Associate Principal, Avalere Health
Sarah Price, Director, Public Health Integration, National Association of Community Health Centers (NACHC)
Kate Berry, Senior Vice President Clinical Affairs and Strategic Partnerships, AHIP
Dan Jones, Senior Vice President, Federal Affairs, Alliance of Community Health Plans (ACHP)
Abby Bownas, Manager, Adult Vaccine Access Coalition

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November 6, 2025 – The latest Summit Summary

Payment Challenges in the New Immunization Environment – Chelsea Cipriano, MPH, Managing Director, Common Health Coalition (CHC); Mitchell Finkel, Associate Principal, Avalere Health; Sarah Price, Director, Public Health Integration, National Association of Community Health Centers (NACHC); Kate Berry, Senior Vice President, Clinical Affairs and Strategic Partnerships, America’s Health Insurance Plans (AHIP); Dan Jones, Senior Vice President, Federal Affairs, Alliance of Community Health Plans (ACHP)

Chelsea Cipriano, MPH gave updates on current vaccine payment policies and systems.

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Payment Challenges in the New Immunization Environment: Chelsea Cipriano, MPH – Common Health Coalition
The Common Health Coalition (CHC) is a membership organization with 350+ healthcare and public health organization members working together to improve the health system in the United States.

Respiratory Season Vaccine Access Is a Team Effort
The Goal: Widespread access for patients and communities
Core Players

  • Payers provide coverage for vaccines
  • Providers order and offer the vaccines
  • Public health operationalizes policy, provides guidance and communications
  • Public makes the choice about getting vaccinated with the information available

Coverage vs. Payment of Vaccines

  • Coverage refers to whether and for whom a vaccine is included as a benefit.
  • Payment refers to how and how much providers (paid by public or private payors, e.g., Medicaid, private plans, Vaccines for Children) are reimbursed for administering the vaccine. These payment parameters can be/are linked to Advisory Committee on Immunization Practices (ACIP) recommendations.

Resources from CHC

  • Toolkits
  • Regulatory/legal briefs
  • Scenario planning tools
  • Explainers
  • Recommendations
  • FAQ

Mitchell Finkel gave updates on current vaccine payment policies and systems.

Medicaid Adult Vaccine Provider Reimbursement in 2025: Mitchell Finkel – Avalere Health
Payment is an important focus because it influences stocking of vaccines, whether a patient can get a vaccine in their given state, and more. For example, a study by the Global Healthy Living Foundation and IQVIA found that “A $13 increase in Medicaid Fee for Service (FFS) total pharmacy reimbursement for adult influenza vaccination is associated with a 5.6 percentage point increase in the state vaccination rate for adult Medicaid FFS population.”

[Adult] Provider spaces are diverse (physicians’ offices, pharmacies/retail, and federally qualified health centers [FQHCs]), and each type has a different payment model. Avalere Health looked at each provider type and analyzed payment rates and methods for vaccinations.

Physician Office Reimbursement
Physician office reimbursements often fall under the medical benefit for vaccine product and administration. There is no federal standard for vaccination reimbursement rates, and the ratio of reimbursement for product (including acquisition, storage, and billing) versus administration (including time to administer, malpractice insurance, and other components) may vary. Generally, when the total payment rate for a vaccine is increased, that is associated with a higher vaccine uptake rate and, when it is decreased, that is associated with a lower vaccine uptake rate.

Vaccine Product Reimbursement Rates Versus List Price
When Medicare reimbursement for a provider-acquired vaccine comes in below wholesale acquisition cost, Medicaid providers might be losing money even before time/administration costs are accounted for. Avalere Health found that:

  • About half of vaccines, including pneumococcal and COVID-19, normally reimburse at or above wholesale acquisition cost; but
  • Several vaccines, including Tdap, RSV, and shingles, reimburse below wholesale acquisition cost.

Vaccine Administration Reimbursement Rates
Every state determines their own payment rates and methods. Avalere Health found that:

  • The median Medicaid administration rate in 2025 was $14.78, well below rates provided by Medicare and commercial payers (e.g., the Medicare Part B fee for service reimburses $33.71; the commercial insurance benchmark is $20.05).

Reimbursement for FQHCs via the Prospective Payment System
Because most FQHCs are reimbursed by pre-determined bundled payment for all services performed during a visit, FQHCs can be disincentivized from administering vaccines to Medicaid beneficiaries.

States Policies Influence Reimbursements to FQHCs

  • Eight states have policies that allow for reimbursement for vaccine product and vaccine administration at every visit, regardless of the rest of the visit and its reimbursement: Arkansas, Idaho, New Hampshire, New York, North Carolina, North Dakota, Rhode Island, South Dakota.
  • Eight states have policies that allow for reimbursement if the patient comes in only for a vaccine, and the FQHC can bill for the vaccine product and vaccine administration: Alaska, Florida, Georgia, Illinois, Massachusetts, Michigan, South Carolina, Washington.
  • Three states have policies that vary but do not financially disincentivize vaccination via negative reimbursement policies: Indiana, Maryland, Missouri.
  • The rest of the states have policies that do not lend themselves to the likelihood that FQHCs would stock adult vaccinations.

For more information, Avalere Health’s white paper “Medicaid Adult Vaccine Provider Reimbursement in 2025: Comparison Across 50 States and Washington, CD” is now available.

Sarah Price gave updates on current vaccine payment policies and systems.

Current Vaccination Landscape in Community Health Centers: Sarah Price – NACHC
Community Health Centers (CHCs) are the largest primary care network in the nation, and the National Association of Community Health Centers (NACHC) is the member body that advocates, supports, and learns from CHCs. In 2024, CHCs served 33.9 million patients and NACHC has 1500+ CHC grantees with a total of 17,000 sites.

Point-in-Time Poll
At a recent convening with NACHC’s health policy committee and clinical practice committee, a point-in-time poll showed the following: Of the CHCs responding:

  • 65% reported financial changes in vaccine programs
  • 47% noted increased workforce efforts
  • 41% experience vaccine access problems
  • 92% observed reduced patient demand for vaccines

Access Barriers
NACHC explored four areas of access barriers:

  • Financial Unsustainability — most CHCs lose money when they give vaccines
  • Limited Program Coverage — the 317-vaccine program covers only adult, uninsured patients
  • Delivery and Logistics Challenges — inconsistent and delayed vaccine shipments
  • Regional and Operational Barriers — smaller CHCs face extra burdens, e.g., with ordering

Cost Challenges

  • Rising Vaccine Costs — not insignificant planning and purchasing predictions
  • Supply Chain Instability — including unpredictable availability
  • Financial Strain — additional costs and preparing for worst-case shortages
  • Workforce and Funding Impact — increased demands and loss of COVID funding

Communication and Safety Concerns

  • Decline in Vaccine Demand — reduced patient demand, especially for COVID-19 and flu vaccines
  • Pediatric Vaccine Hesitancy — parents preferring to spread or limit vaccinations, which increases visit times
  • Strain on Healthcare Staff — longer visits to address misinformation
  • Efforts to Rebuild Trust — use of social media, education, and advocacy

Recommendations and Collaborative Strategies
Ninety-two percent of CHCs support NACHC partnering with organizations to improve vaccine access and materials by:

  • Rebuilding public trust through consistent unified messaging from clinical teams
  • Using community engagement strategies to help dispel misinformation and understand concerns
  • Building resilient healthcare through collaborative, community-based approaches

Kate Berry gave updates on current vaccine payment policies and systems.

The Health Plan Perspective: Kate Berry – AHIP
Health plans view vaccines as a high value tool for preventing infectious disease. America’s Health Insurance Plans (AHIP) made a statement in September 2025 regarding ongoing coverage of vaccines with no cost-share to patients. The timing was intentional to include the ACIP recommended vaccines as of September 1, 2025. The statement covered payment through 2026, including the latest flu, COVID, and RSV vaccines.

States and Coalitions in the Current Environment
States and coalitions have come together to promote access to vaccines. This does create variability state-to-state, but state regulations, executive orders, or legislation are important and can expand what pharmacists can do in terms of vaccine administration. Some states, however, like Florida, may be seeking to minimize or eliminate mandates for school requirements for immunization.

Future Landscape for Policy Recommendations
Policy recommendations under ACIP have not been a challenge, despite concerns regarding the childhood immunization schedule and recommendations for vaccines for pregnant women. There is also a trend toward clinical decision-making. Collaborative groups are coming together — medical societies, the Vaccine Integrity Project, the Common Health Coalition, and employer groups — to make sure that people have vaccines that are recommended for them and to try to increase uptake.

Dan Jones gave updates on current vaccine payment policies and systems.

Confidence, Coverage, and Access: Dan Jones – ACHP
The Alliance of Community Health Plans (ACHP) represents 30 nonprofit provider-aligned, community-based health plans across about 40 states and covering about 24M people across Medicare, Medicaid, the marketplace, and the commercial market. Members are either part of a fully integrated healthcare delivery and financing system or maintain strong provider partnerships within their communities. ACHP members continue to be committed to vaccine coverage and keeping individuals and communities healthy.

In the current environment, ACHP has assured public policy makers that their member companies will continue to cover routine vaccinations with no cost-share, including respiratory season vaccines, and will continue to be guided by clinical evidence and public health consensus.

Despite concerns about public confidence, ACHP believes that vaccine guidance should be independent, science-based, and transparent — both to preserve coverage and maintain public trust. ACHP and its members are continuing to promote vaccination and their view on the model of care and preventive care, along with monitoring federal- and state-level changes and attempting to minimize confusion and the potential for disruption of access to vaccines.

QUESTIONS & ANSWERS

Q: Don’t we need to be very clear and talk about this as payment and not reimbursement?
Chelsea Cipriano (CHC): Purely from the public perspective, the perception, the language that is used at that level, and what the public needs to hear from us as the experts communicating about it, is that they won’t have to pay out of pocket; and when they hear, “reimbursement” or “coverage,” [there are] eyes glazing over. From the purely public, non-technical perspective, people know what payment means, they know when they have to pay for something and when they don’t.
Kate Berry (AHIP): Let’s face it, the people with insurance coverage, no out-of-pocket cost to them…doesn’t mean it’s free: somebody’s paying for it, but if you have insurance, you’re covered, no out-of-pocket cost to you. We know that we need a safety net: not everybody has insurance. That’s why the Vaccine for Children’s program is super important: it covers, typically, half of kids that may be underinsured or uninsured. And we need a safety net for others, as well. So, from the health plan perspective, we can only focus on making sure that we’re doing our job and taking that barrier off the table. But we also must have a safety net for others, and that may be more at risk at this point, just to be totally honest with the audience.

Q (follow-up): I think the other perspective about reimbursement versus payment is that you’re really not reimbursing a provider, you are paying the provider for an important service. Any thoughts about this idea of the language used: reimbursing a provider for their service provided versus paying the provider?
Mitchell Finkel (Avalere Health): I was trained as a biller, where every physician always has a staff behind them trying to make sure that they are paid the appropriate amount. The clinician, the staff, and those professional billers are always using the term reimbursement, because at the very least, when it comes to vaccines, we see the number that was paid for that product — we’re trying to match that number, and it’s very hard to not get outside the term of reimbursement in that respect, just because we’re trying to reconcile. But I want to know about the perspective when we think about the advocacy realm. I can see payment being a key term there.
Abby Bownas (AVAC): It’s like that public-private conversation: We use provider support as a general [way to] talk about it outwardly, but reimbursement is like a CMS terminology. So, if you’re trying to fix something in legislation, you would want to use terms that kind of match what’s happening behind the scenes. So, I think it’s a “both, and,” and certainly, when we talk about it, we want to make sure patients and individuals know there’s no cost to the vaccines. When we talk to The Hill, we talk about supporting providers and offering vaccines. And when we talk to the agency, we talk about reimbursement.

Q: Can the panel talk about bundled payments, like hepatitis B during birth hospitalizations? How do new vaccines like RSV become part of the bundle payment?
Mitchell Finkel (Avalere Health): I think underlying this entire presentation, [is the idea that] healthcare is extremely complicated. Every provider has a different payment system to ensure that it matches their clinical workflow and their economic workflow. Regarding bundled payments, as discussed in FQHCs, there’s something called the prospective payment system, which is similar to a bundle payment, but not exactly the same. Bundled payments are most common in the hospital setting. So, when we think about RSV and hepatitis B birth dose, often a hospital will be paid for all the services they provide under one payment system. And that’s just to ensure that there is a standard of care and a payment rate. There was definitely a larger concern when RSV immunizations were launched, when these were relatively higher cost immunizations. And for some hospitals, the economics may not have supported administering the RSV monoclonal antibody within the hospital setting, just based on that bundle payment. There are a number of workarounds that many hospitals are pursuing. And it depends on their mix of payers, their ways of working, but know that a lot of those [issues] are being addressed both with payers and on the VFC side, ensuring that [patients] can acquire a dose for free. So, when available to a hospital, many are trying to adopt it as a standard of care in the hospital setting, given that it’s best to administer within one week at birth.
Sarah Price (NACHC): At most FQHCs, and again not all, because we see some state outliers, but at most if you get one shot, or two shots, or three shots, there’s still one payment. So, yes, it’s bundled, but it’s inadequate for most of that. So, that’s unfortunately how most FQHCs must work through it.

Q (follow-up): Initially when RSV was added to the maternal schedule, a lot of maternal providers (e.g., OB-GYNs) had bundled payments, as well. Any perspective about the impact of bundle payments, especially when vaccines like RSV are added?
Kate Berry (AHIP): One of the questions that we’ve addressed frequently relates to RSV immunization for babies, which is such a wonderful breakthrough that we have that available. I’m not the value-based payment person for AHIP, but I’ve been in these meetings multiple times. And those are not the cheapest vaccines we have on the table, but [they are] super breakthrough [products] to protect the babies. I know everyone loves to blame the payers, but in this case, as I understand it, the hospitals must bill it in order for it to be incorporated into the bundle over time. The colleagues [have questions related to whether] we are paying enough; at the same time, the manufacturers [are saying,] “We don’t set the prices of the vaccines.” Most vaccines [are] dirt cheap [for their] high value. RSV is a bit different: still a breakthrough, saving babies, and plans started to cover before it was required.

Q: In general, how are plans (member plans, associations representing member plans) viewing the individual patient-making, or the shared clinical decision-making, recommendation. Do you all view it as a ‘must-cover’ when it comes to vaccines that have that kind of recommendation?
Dan Jones (ACHP): Generally speaking, we’ve been supportive of patients being able to have conversations with providers about receiving the vaccines appropriate for them and being educated on making that decision. It is not a requirement for purposes of coverage with no cost share. If an individual is going to get the vaccination, it’s not a prerequisite that has to be done in order for that to happen.
L.J Tan (Immunize.org, NAIIS): What I’m hearing you say is that you’re broadly covering shared clinical decision-making, and there’s no need to document that you’ve had that conversation, necessarily.
Kate Berry (AHIP): 100% agree with Dan. Every conversation I’ve had on vaccines, and there are many, this often comes up: Ask a doctor, ask a pharmacist, ask any clinician, “Hey, are you just sticking the vaccine in with no conversation?” I don’t think so. This is a normal part of the process: Clinicians are going talk to their patients about their vaccine. So, yes, covering clinical decision-making with no documentation, as far as we know, for sure.
Chelsea Cipriano (CHC): We have a document on shared clinical decision-making that doesn’t get into the payment stuff but is hopefully helpful for anyone who is having this confusion that Kate is so well articulating. People do this. This is what folks are doing, and the more that we can describe this, both to providers and patients, that this isn’t like another doctor’s appointment: This is what vaccine counseling is, and what is already happening. Please use this document, and we’ve built some additional liability questions into it after a webinar.

Q: Will the data that you presented become public? And, do you have a sense whether it’s vaccine confidence confusion that’s driving these declines, or is there another reason?
Sarah Price (NACHC): Question number one: It wasn’t really a scientific poll, to be honest. It was more of a convening. That said, this is why we want to share this in convenings [current Summit meeting] like this. We also met with Abby Bownas yesterday at AVAC to say, “Hey, here’s what went on.” So, we’re tapping the boots on the ground on a consistent basis. We’ll be doing it almost every month here just to make sure that we’re steering in the right direction on that. So public, not really. It was a poll on a Zoom call, but it helps us to know what’s happening then, what can happen now, what’s happening there. I think, in the conversation we had about a decline, it was about (half) 50% declines, [maybe] because the COVID shot came in late, I don’t really want it, and I’m nervous about it. Or, just until the vaccine program figures itself out, I don’t want to take part now. I think, if anything, there might be — and this has happened other years, as well — declines now and then, like, Oh, now I want it in January. Everything’s kind of figuring itself out, and not all providers even have those vaccines in stock yet. So, I think, if anything, it’s because it was a point in time in October, it was almost too early. But folks were saying… like the conversations I’m having right now are not pro-vaccine, yet, but I personally think we’ll see an increase. It’s complicated, as we know.

Q/Comment: On the reimbursement versus payment issues, it needs to be remembered that the organization is what receives the money, whether it’s called reimbursement or payment; but what incentivizes the clinicians is how they are compensated. That is, in most non-small practice settings, the clinicians do not directly benefit from the reimbursement/payment. In contrast, there can be incentives set up to encourage or discourage clinicians from promoting or not certain services such as vaccinations. Ideally, individual clinicians would be highly compensated — incentivized — to provide vaccines because of the clinical and economic value immunizations provide to the health system, to the community, and to patients. So, I think it’s a very cognate statement. I think it’s a good one. I just want to open that up, see if any of our panelists wants to respond to that. I think it’s a policy discussion going forth, whether there are ways, working within healthcare systems, to incentivize individual clinicians on vaccinations, for example?
Chelsea Cipriano (CHC): I think many in the public believe that physicians are being paid cash for every vaccine that they are administering, and that is something that we encounter and must be careful with. We did a cool program during COVID in New York City. Seven health insurers partnered with the city health department to incentivize vaccine education to their physician members, or covered physicians. So, I can drop the paper that we wrote about it in the chat. It was a really successful program, and I think it can be replicated in the future, if needed, for other vaccines, not just COVID.
Kate Berry (AHIP): This is a really challenging issue: do we pay enough? How do you structure payment or incentives? I mean, I guess I would just make a plug here for fee-for-service, maybe not the perfect model to promote incentives for providers and patients to get the best care that’s going to result in good outcomes at a good, affordable price, if you will. I think there was a fee-for-service mentality in the question; I do feel like, if we can transition more to incentives for outcomes, prevention, vaccines, reducing disease, better managing chronic conditions, etc. — I do feel like value-based care creates better incentives around this.

Q: Some insurance plans cover immunizations outside of the bundle when they’re administered in a hospital setting: Is there a way to work on this at a national level with payers to increase the practice as more immunizations become available in the future?
Dan Jones (ACHP): Would need to have some more understanding myself, but I’m always open for a negotiation and talking about where the opportunity is.
Kate Berry (AHIP): If there are folks that want to chat, [I’m] happy to have that conversation and bring in the right colleagues at AHIP. Plans make their own decisions, though, about their contracts, and we don’t get in the middle of that, but, at the same time, we like to solve problems when we can and work with our members to do that. So, happy to entertain feedback.

Q: Clarification on SCDM: You said that payers are going to pay SCDM not requiring any kind of documentation or counseling. Do you view vaccines with shared clinical decision-making recommendations as a routine immunization, and therefore required to be covered without cost sharing?
Kate Berry (AHIP): Yes.

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Congressional Perspective and Policy Overview – Abby Bownas, Manager, Adult Vaccine Access Coalition

Abby Bownas gave an update about vaccine-related legislative news.

Congressional Perspective and Policy Overview – Abby Bownas, AVAC
The Adult Vaccine Access Coalition (AVAC) is 10 years old and has members that include providers, patient groups, and vaccine innovators. They work to improve access to and utilization of vaccines.

Note: As of this meeting, the U.S. government had been shut down for more than one month. Although this is usually the time of year for updates about appropriations and funding, government operations are currently frozen.

Congressional Legislation on ACIP
Democrats have introduced bills to protect vaccine access:

  • Protecting Free Vaccines Act — Sponsored by Rep. Pallone (NJ-06) + 65 cosponsors; Sen. Wyden (OR) / Sanders (VT): Ensures no-cost vaccines in Medicare, Medicaid, Private Insurance
    • This bill seeks to ensure that systems created to make sure that vaccines have no cost to individuals are maintained/set in statute. AVAC’s coalition has put together a partner sign on letter on this bill.
  • Family Vaccine Protection Act — Sponsored by Rep. Pallone (NJ-06)/Rep. Schrier (WA-08); Senator Hickenlooper (CO): Codifies ACIP structure, process, and role.
    • This bill was set up when there were immediate changes happening to ACIP.
  • VACCINE Act — Sponsored by Sen. Blunt Rochester (DE): Asserts that members that had previously been on ACIP should be reinstated.

Congress and the End-of-Year Package
There will likely be an end-of-year package, post-shutdown, that will include extenders for things like the physician fee schedule, CHC funding, ACA enhanced premium tax credits, telehealth, and pandemic reauthorization. AVAC has put together end-of-year recommendations and is providing related education on The Hill. The recommendations include protecting no-cost vaccines, protecting vaccine provider reimbursement, and support for health centers and long-term care facilities.

AVAC Core Values
AVAC has created a core values document that lays out their principles and is a sign-on opportunity for AVAC and friends of AVAC. It is posted on AVAC.org and shared with partners on The Hill.

QUESTIONS & ANSWERS

Q: Is it possible that this could all get rolled into the bill to reopen the government?
Abby Bownas: Oh, everything I’ve asked for? No…sorry, LJ.

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Announcements
  • CDC COVID recommendations and clinical considerations are now out.
  • Save the date for the 2026 National Adult and Influenza Immunization Summit in-person meeting: May 19 – 21, 2026 at the Crowne Plaza Atlanta Perimeter at Ravinia in Atlanta, GA.
  • The Summit Payment Working Group has made new smart vaccine purchasing documents available. The package includes terminology for contracts and payments for immunization services, Excel worksheets for understanding contracts and margins, and a downloadable Excel spreadsheet for for individual circumstances. They can be found [here].

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