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Vaccination remains a foundational component of public health; however, adult immunization rates in the United States continue to be below national goals. Since 2021, Avalere Health has analyzed Medicaid provider reimbursement for vaccines to inform policy discussions concerning barriers and facilitators of access. The 2025 assessment builds on prior analyses and reflects a markedly different policy landscape shaped by the Inflation Reduction Act, evolving Advisory Committee on Immunization Practices (ACIP) guidance, and fiscal pressures introduced by the One Big Beautiful Bill Act. Together, these changes highlight ongoing challenges in facilitating vaccine access.

Avalere Health’s 2025 review included Medicaid fee-for-service reimbursement for five vaccine categories: respiratory syncytial virus (RSV), tetanus diphtheria and acellular pertussis (Tdap), pneumococcal conjugate vaccine, shingles, and COVID-19. We examined reimbursement across physician offices, pharmacies, and Federally Qualified Health Centers (FQHCs), with two key findings:

• There have been relatively few changes in the Medicaid vaccine reimbursement landscape compared to prior assessments. In most states:
  • Physician offices continue to be reimbursed less by Medicaid than Medicare.
  • Pharmacies continue to receive wholesale acquisition cost-based reimbursement for vaccine products and relatively low rates for vaccine administration.
  • FQHCs are not able to separately bill from the Prospective Payment System for vaccine products and administration.
• Several targeted changes in Medicaid reimbursement were observed in 2025:
  • Administration rates for non-COVID-19 vaccines have increased modestly, whereas reimbursement for COVID-19 immunization administration has declined in multiple states.
  • The number of vaccines for which pharmacies are permitted to seek reimbursement has expanded.
  • A greater number of states now allow FQHCs to bill separately for vaccine products and administration under defined circumstances.

Looking ahead, Medicaid vaccine reimbursement policy is poised to face additional stressors. ACIP’s planned re-review of immunization recommendations could alter federal coverage requirements, potentially restricting access in some states. Moreover, provisions in OBBBA are expected to constrain state budgets.  As stakeholders look to safeguard vaccine access, ensuring adequate reimbursement for vaccine products and administration can help support ongoing access for Medicaid beneficiaries.

Download the white paper.