MedicaidCoverageMedium impact
PT 22-26: Clarification on Medicaid Coverage of Pediatric Vaccines
Maryland Medicaid·MD · Pediatrics, Family Medicine, General Practice·Medical Policy
Effective date
Sep 24, 2025
We identified it
Jun 18, 2026
Summary
Maryland Medicaid updated guidance on pediatric vaccine coverage following recent FDA and ACIP changes. COVID-19 vaccines for ages 6 months-18 years now use individual-based decision-making, and MMRV combination vaccine is recommended for children 4+ years old, though MCOs won't cover MMRV costs for under-4 age group as long as separate vaccines remain available through VFC.
Action Required
Immediately: Billing team must ensure VFC vaccines continue to be billed with SE modifier appended to vaccine codes. Verify all EPSDT providers administering pediatric vaccines remain enrolled in VFC program. For children under 4 years, bill separate MMR and Varicella vaccines through VFC rather than MMRV combination vaccine to avoid MCO coverage issues.