Medicaid but cannot afford private health insurance. CHIP is available to citizens and some legal immigrants, and states can charge a premium for coverage and impose cost-sharing based on income. States have the option of using the grant money to establish independent insurance programs or to expand eligibility criteria for Medicaid; in the latter case, the coverage must conform to Medicaid requirements. Currently, 39 states have programs that are not expansions of Medicaid. Non-Medicaid CHIP programs must provide coverage for ACIP-recommended immunizations, including hepatitis B, and must meet a federally established minimal overall coverage.

Public programs for adults. Nonelderly adults have more limited access to publicly funded vaccination programs and public insurance benefits than children. Adults enrolled in Medicaid make up 25% of enrollees and are provided coverage for vaccinations, but the coverage varies between states. Most states provide coverage based on ACIP standards, including hepatitis B immunization. However, cost-sharing is common, and payment of providers varies from fixed-fee schedules, which allow separate billing for vaccine administration (Rosenbaum et al., 2003). Elderly adults covered under Medicare and enrolled in Medicare Part B are covered for hepatitis B vaccination if they fall into ACIP-designated high-risk or intermediate-risk populations. The Medicare Part B deductible must be met, and the relevant copayment or coinsurance is applicable to the hepatitis B coverage (CMS, 2008).

Federal law generally restricts coverage for adults under CHIP to pregnant women but does permit coverage of adults without dependent children under special waivers from the federal government. Eleven states are providing coverage to low-income adults under such waivers. The 2009 CHIP reauthorization act will phase out funding for such waivers by 2011 and thereby eliminate this public source of adult-vaccination coverage (Families USA, 2009a). Public Health Service Section 317 grants amounted to $527 million in 2008 and allow vaccination coverage for uninsured and under-insured adults. Nearly all the money, however, was used for vaccinating children and youths. In 2005, it was reported that less than 5% of Section 317 funding was used for adult-vaccination efforts (Mootrey, 2007).

Private Insurance Plans

Employers provide over 66% of all health insurance for 177 million Americans under the age of 65 years (U.S. Census Bureau, 2007). Trends in private health-insurance coverage have reflected a shift from comprehensive coverage with low out-of-pocket costs (health maintenance organizations, HMOs) to broader access, network-driven, and higher-cost–sharing health plans (preferred provider organization, PPOs) (Figure 4-2). The latter offer

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