Immunization Update Call 9/11/2012 CDPH Immunization Branch These slides are posted on the Immunization Coordinators’ website

Topics Covered on Today’s Call 317 Policy Flu Season State-Purchased VFC Legislation Update Medi-Cal Increased Reimbursement AB 354

Section 317 Immunization Program Vaccine Funding: National 317: Discretionary funding through Section 317 grant funds. This funding has historically allowed the State to expand eligibility for vaccines. 317 vaccine funds are made available to states to use according to local needs. The use of 317 varies from state to state, but was historically used for non-VFC eligible children in public clinics and limited vaccines for adults. 3

New CDC Guidance: 317 Vaccine CDC has announced that effective October 1, 2012, 317 vaccine can no longer be used on privately insured individuals. Implications: LHDs would have to either bill private insurances or refuse service to insured clients and refer them to their medical home.

New CDC Guidance: 317 Vaccine 317 vaccine funds may be used to vaccinate the following: Underinsured children Uninsured or underinsured adults Fully insured individuals seeking vaccines during public health response activities including: Outbreak response Post-exposure prophylaxis Disaster relief efforts Mass vaccination campaigns or exercises for public health preparedness Influenza vaccine, 2012-2013 Season

New CDC Guidance: 317 Vaccine Fully Insured: Anyone with insurance that covers the cost of vaccine, even if the insurance includes a high deductible or co-pay, or if a claim for the cost of the vaccine and its administration would be denied for payment by the insurance carrier because the plan’s deductible had not been met. Underinsured: A person who has health insurance, but the coverage does not include vaccines or a person whose insurance covers only selected vaccines. Children who are underinsured for selected vaccines are VFC-eligible for non-covered vaccines only through a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC).

Implementation of Policy Initial letter sent to Health Officers: Sent 7/13 Presentation to CCLHO: Done on 8/2 Eligibility Tables, and Insured Policy: Sent 8/31 Templates for provider communications: Sent 8/31 New signs for LHDs: Sent 8/31 Outreach to physicians: Emails to EZIZ, provider organizations: Sent 9/4-5 Revisions of policies at LHD level Training of staff on new 317 guidelines

2012-2013 Flu Season Vaccine influenza virus strains A (H1N1) California/7/2009-like (same) A (H3N2) Victoria/361/2011-like (new) B Wisconsin/1/2010-like (new) Manufacturers expected to bring 146-149 million doses to the market for 2012-2013 season FDA maintains a webpage where information on lot releases are updated once a week

Flu Vaccine Shipping

Status of state-purchased vaccine shipments Fluzone multi-dose vials Fluvirin multi-dose vials Fluvirin single dose syringes Flumist sprayers Fluzone Intradermal Order 186,000 164,000 78,000 9,000 Available at McKesson Shipped to LHDs 100% Shipping Shortly Doses still available 6,000

VFC 2012-2013 Fluzone - Sanofi 0.25mL Syringes Fluarix - GSK 0.5mL syringes FluMist - MedImmune Nasal Sprayers Sanofi MDV Fluzone 10 Dose Vials VFC Ordered 560,500 370,000 380,000 500,000 VFC Received 202,490 298,890 Percentage Received 36% 100% 60% Shipped to Providers Orders under 100 doses=Filled Orders over 100 doses = 20% Orders over 100 doses = 50% To be processed the week of September 10th ??? Fill remainder of orders

VFC-Provider Communications VFC Letter with ACIP Recommendations: Sent Initial Provider FAX Blast: Sent Heads up on flu vaccine shipments, program letter and reminder on flu vaccine returns. 2nd Provider FAX Blast: To be sent this week Heads up on flu vaccine shipments Supplemental Ordering Notification: When site is launched. Site will be likely to be live at the end of the month.

2012-2013 Replacement Program Unused, Expiring LAIV Doses must be purchased through the CDC contract Doses must expire by January 31, 2013. Providers have from 15 days prior to the lot expiration date until January 31, 2013 to request replacement doses. Any doses sent prior to 15 days of expiry will not be replaced. All requests should be placed by calling McKesson Specialty Health Distribution at 1-877-633-7375. All expired/expiring doses must be received by 2/15/2013. Replacement doses will not be shipped until expired /expiring doses are received.

Pediatric 0.25 Fluzone Currently available vaccine was purchased with combination of VFC and 317 funds Like other pediatric vaccines, this allows LHDs to immunize anyone that comes to their clinics. Like other pediatric vaccines, VFC screening must be done. 317 policy change will not affect eligibility to receive pediatric Fluzone for this year.

LHD eligibility screening Screening necessary when using VFC: multidose vials, single dose-syringes, LAIV 317-purchased vaccine: 0.25 ml syringes No screening needed for State-purchased supplies 3 years and older: multidose vials, single dose-syringes 2-49 years, healthy, not pregnant: LAIV Survey sent to measure LHD demand for state-purchased 0.25ml syringes for <3 years of age Investigating option for this season to reduce screening

Examples for mass vaccination clinics Vaccine supplies Who may be vaccinated? Eligibility screening needed? County A State-purchased TIV > 3 years LAIV 2-49 years No County B State-purchased VFC, 317 > 6 months Yes County C State-purchased + VFC/317 for 0.25 mL syringes Only recipients of 0.25 mL syringes

Flu Communications 2012-13 Flu Dosing Guide for children 6 mos through 8 years of age Flu Vial ID Guide CDC flu kick-off press briefing – September 27 National Influenza Vaccine Week (NIVW) – December 2-8 CDPH flu press release - October?

Flu Communications Seasonal flu messages for the public: Promote universal flu recommendation. “Flu is a serious disease that can lead to hospitalization and sometimes death.” “The flu vaccine is not just for seniors. Anyone can get sick from the flu.” “Everyone over 6 mos. of age should get immunized.” “Flu seasons are unpredictable. Get vaccinated today to have protection throughout the flu season.”

Flu Communications Free hard copies of flu materials available by CDC: http://wwwn.cdc.gov/pubs/ncird.aspx#Flu

Walgreen’s Voucher Program Walgreens is planning on offering vouchers at designated vaccination clinics and other venues Would like to offer vouchers deliver vaccine to uninsured who are unable to afford influenza vaccination themselves. Interested in working with local health departments who could give these to uninsured adults, for example, and these vouchers could then be redeemed at a Walgreens. Health departments interested Walgreens may contact: Jeff Ackerman (Jeff.Ackerman@walgreens.com).

Current Legislation AB 2109 – Pan Parents seeking PBEs would submit to schools a form signed by the parent and a health care practitioner who has provided information about vaccines and the diseases they prevent. Similar law in Washington State decrease in kindergarten PBEs in 2011 Governor’s Desk

Current Legislation SB 1318 - Wolk Who: All onsite healthcare workers, and staff with privileges; can also apply to contract workers Where: All clinics and health facilities What: Worksites with HCW influenza immunization rates <90% subject to masking policy TBD by CDPH and stakeholders in 2015 and beyond. Governor’s Desk

Current Legislation AB 2009 – Gagliani CDPH’s influenza vaccine for LHDs – CDPH may provide guidance on prioritizing doses, based upon ACIP recommendations or other criteria Governor’s desk SB 659 - Negrete McLeod Permit inclusion of TB testing data in CAIR Signed by Governor

 Reimbursement for administration MediCal beneficiaries, 2013-2014 March, 2010: Provision in the Affordable Care Act (ACA) increases Medicaid payment rates to at least 100% of Medicare rates in 2013 and 2014 for certain primary care services and immunizations. May 11, 2012 Federal Register - Proposed Rule June 2012 - Supreme Court upholds ACA Autumn 2012 – Final Rule to be issued Amendments to Proposed Rule? January 2013-December 2014: Rule in effect

 Reimbursement for administration MediCal beneficiaries, 2013-2014 Current reimbursement - $9 For 2013 and 2014, increase to the lesser of Medicare reimbursement for immunization >$25 in California, depending on region Nov 2012 – 2103 Medicare rates will be posted New proposed maximum for VFC immunization $17.55  $26.03 in California States will receive 100 percent federal funding to cover the increase in payments ($25-26 minus $9). Applies to immunization at any age, not just VFC Applies to managed care as well as fee-for-service

 Reimbursement for administration MediCal beneficiaries, 2013-2014 VFC: Same for combination as individual vaccines Services must be delivered by practitioners supervised by qualifying physicians: Family medicine General internal medicine Pediatric medicine, including subspecialists >60% of MediCal payment claims for primary care Reimbursement policy separate for other VFC categories: Uninsured, Underinsured, Amer. Indian Also separate for FQCHCs/RHCs

 Reimbursement for administration MediCal beneficiaries, 2013-2014 Potential source of funding in 2013 and 1014 for immunization in your LHD Additional >$16 per each immunization 1-2 million doses of VFC vaccine given by LHDs in 2011 MediCal population will increase – Healthy Families, ACA Are you ready to bill MediCal? Where in your system will MediCal reimbursement go? Brainstorming – How might this funding assist local immunization capacity? Possibilities include augmented Staffing, School-located immunization, Other Possibility of CAIR assisting in billing

AB 354 - 2012-13 and future school years Pupils needing proof of a Tdap booster shot before starting school: All entering or advancing into 7th grade All transferring from out-of-state or country into 8th through 12th grades Exclusion if haven’t met requirement Applies to all public and private schools About 500,000 students affected As of Sept. 2012 - no extension periods

AB 354 Communications Weekly Emails to CA Private and Public Schools serving 6th and/or 7th Grade Students Bi-weekly Emails to Providers 7th Grade Assessment Report due November 1, 2012 – See CDPH Memo

AB 354 Efforts In Your Schools – How Did it Go? Reporting Reminders for Local Schools: Child Care Assessment Due 10/1/2012 Kindergarten Assessment Due 10/15/2012 7th Grade Tdap Assessment Due 11/1/2012