Allowable Costs for Immunization

This memorandum provides policy clarification about WIC allowable costs for activities related to immunization promotion in the WIC program.

Background

Since 1978, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) has had a legislative mandate and, consequently, regulatory responsibility to coordinate with immunization services. Section 246.4(a) (8) of the WIC program regulations requires each state agency to describe its policies and procedures for coordinating with and referring participants to a variety of allied nutritional and primary health care services. Among the services that must be addressed in this regard are immunization services.

Using this legislative history as a base, at a minimum, WIC is required to refer participants to available immunization services. An assessment of each participant's immunization status at the time of certification and subsequent referral to appropriate immunization services, if needed, is a responsible and appropriate way in which to respond to program regulations in this area. While sophisticated client immunization need assessments enhance the effectiveness of referrals and are encouraged where possible, the assessment process and emphasis may vary based on local WIC resource availability.

The WIC program and the Centers for Disease Control and Prevention's (CDC) National Immunization Program have initiated a cooperative effort to increase immunization rates among preschool- age participants in the WIC program. Because of this increase in immunization promotion, many questions have arisen regarding the allowability of costs for activities related to immunization promotion in the WIC program.

Allowable WIC Costs

The costs of WIC participant immunization assessment, referral, education, and caseload management are allowable WIC costs. For example, the cost of developing and printing educational materials could be an allowable WIC cost if the publication were targeted to and used for WIC's population. If such a publication is also intended for use in programs other than WIC, those programs should pay a fair and equitable share of the costs. A cost sharing plan between programs (at the state or local level) would help formalize the financial commitments of all involved programs.

WIC funding is not generally intended to duplicate available services from other programs. While WIC may fund the above cited costs for WIC participants, it may first wish to use other available resources to conserve its own for other WIC purposes. Other federal and state resources available to support immunization services for WIC participants include Title V Maternal and Child Health grants; the Early Periodic Screening, Diagnostic, and Treatment Program; immunization grants, including Immunization Action Plan (IAP) funding, provided by CDC; and state and local appropriated funds for these purposes.

IAP funding is intended to provide support to communities to improve their vaccine delivery infrastructure and help communities create networks to provide access to and improve the quality of immunization services, aiming particularly at children in their earliest years. The funds are to be used to ensure that vaccines are available and administered to children less than 2 years of age. The funding assists states and localities in the following: removing barriers to immunization; reducing missed opportunities to vaccinate; measuring immunization coverage rates; raising awareness among the public, parents, and providers; and stimulating innovative approaches to improving immunization levels in vulnerable children. It is important to note that CDC funding may be used for a variety of WIC immunization services and activities including, but not limited to, immunization assessment, referral, education, caseload management, and the purchase and administration of vaccines.

Non- allowable WIC Costs

WIC funds may not be used for purchasing vaccines or administering vaccines. In no instance are the costs, which are associated with the delivery of acute or primary health care services, such as purchasing and administering vaccines and medical equipment (i.e., oxygen units, syringes, etc.), allowable WIC expenditures.

Cost Distribution Methodologies

To assure that WIC can effectively serve as a catalyst for the shared health goal of promoting immunizations, qualified medical professionals working in WIC local agencies may be used to administer vaccines to WIC participants if a mutually agreed upon arrangement is made for full reimbursement from non-WIC sources. Determination of an appropriate level of reimbursement to WIC can be accomplished in a number of ways. One concept, known as "fee-per-shot," is a negotiated arrangement between WIC and immunization programs at the state and local levels. The "fee" is the cost to state or local immunization programs to equitably reimburse the WIC program for the full cost of administering vaccines. This permits vaccines to be administered with non-WIC funding sources within the framework of the typical WIC clinic visit as a convenience and service to WIC participants. This is particularly desirable if alternative vaccine delivery systems are inadequate or nonexistent. State and local agencies must, however, assure that the fee continues to be fair and reasonable over time, with regular renegotiations as necessary. Additionally, WIC agencies must assure that WIC services are not adversely affected if WIC staff are assigned to do non-WIC (albeit reimbursed) activities.

Assurance of a reasonable basis for determining fair and full reimbursement does not imply intensive time/cost allocation data systems. Rather, systems must be in place that indicate the salary, benefit, and other direct costs that are charged to WIC. The appropriateness of these charges can be established through a variety of mechanisms that, again, should be described in state/local agency agreements (e.g., time studies, cost-sharing agreement, time and use plans, job descriptions, etc.). State or local health agencies should develop policies which clearly delineate immunization activities to be paid with WIC funds and those to be paid with other federal or state funds. Because immunization assessment, referral, education, and caseload management could be paid by WIC as well as other programs, the policy should fairly allocate the payment of services among all potential funding sources.

FCS has an obligation to ensure that any expenditure of WIC funds is an appropriate WIC cost. At the same time, however, the WIC program should not lose sight of its larger mission to promote the health and well-being of its participants. State and local agencies are encouraged to use the WIC program as an important means of access to health care. For many participants, the WIC program may be their only consistent point of contact with public and private health services.

STANLEY C. GARNETT
Director
Supplemental Food Programs Division