COVID-19 Vaccination Data Access and Strategies Used to Improve Immunization Rates (GAO-24-106526)
Summary
A GAO report to congressional requesters, GAO-24-106526, dated April 2024, on Medicaid and COVID-19 vaccination. It reports that six selected state Medicaid programs varied in their ability to obtain data on beneficiaries' COVID-19 vaccinations from state immunization information systems during the COVID-19 public health emergency from 2020-2023. It explains that these systems, maintained by state public health departments, were the primary source of such data during the emergency. The report also describes strategies the states used to improve immunization rates among Medicaid beneficiaries.
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United States Government Accountability Office
Report to Congressional Requesters
MEDICAID
April 2024
COVID-19 Vaccination
Data Access and
Strategies Used to
Improve Immunization
Rates
GAO-24-106526
April 2024
MEDICAID
COVID-19 Vaccination Data Access and Strategies
Used to Improve Immunization Rates
Highlights of GAO-24-106526, a report to
congressional requesters
Why GAO Did This Study What GAO Found
Given the importance of COVID-19 Six selected state Medicaid programs GAO reviewed varied in their ability to
vaccinations in preventing severe obtain data on beneficiaries with COVID-19 vaccinations from state immunization
outcomes, such as hospitalizations and information systems during the COVID-19 public health emergency from 2020-
death, ensuring Medicaid beneficiaries 2023. During the emergency, these systems—maintained by state public health
receive the vaccine is important. departments—were the primary source of such data. This was because providers
However, state Medicaid programs did administering COVID-19 vaccinations were required to report to them.
not always receive information on the Specifically, state policies—which govern provider reporting requirements and
vaccination status of beneficiaries data sharing—in effect prior to the emergency enabled Medicaid programs in four
directly from providers during the
selected states to obtain patient-level vaccination data from state immunization
public health emergency. This was in
information systems. In contrast, state policies in effect prior to the emergency in
part because vaccines were purchased
by the federal government rather than two selected states either did not specify or did not permit such data exchange.
by insurers like Medicaid. COVID-19 Vaccination Data Collection and Transmission to Certain State Medicaid Programs
GAO was asked to examine Medicaid
programs’ access to and use of data
from immunization information systems
to improve COVID-19 vaccination rates
among beneficiaries, and factors
contributing to data completeness. This
report describes (1) the extent to which
selected states’ Medicaid programs
obtained patient-level COVID-19
vaccination data, and any factors State officials and stakeholders described interoperability gaps between state
affecting data availability and quality; immunization and Medicaid systems, the volume of vaccination data collected,
and (2) how that data helped inform and other factors as affecting the availability and quality of COVID-19 vaccination
selected states’ strategies to improve data collected by immunization information systems during the COVID-19 public
COVID-19 vaccination rates, and health emergency. State officials described how some factors resulted from the
information on the effectiveness of public health emergency. They also noted solutions they implemented as the
such strategies. emergency progressed, such as using a temporary storage system for the
GAO reviewed relevant federal laws, increased volume of data. State and federal officials also identified state policies
interviewed federal agency officials, as as continuing to be important drivers of vaccination data collection and data
well as reviewed information and sharing with Medicaid programs after the public health emergency.
interviewed officials from state public
In the four selected states with access to patient-level data, GAO found that
health departments and Medicaid
Medicaid programs used the data to implement two types of strategies to
programs in six states. The states were
selected based on characteristics of
increase COVID-19 vaccination rates: incentives and targeted outreach. For
their Medicaid and immunization example, one state awarded incentive payments to its 25 managed care
programs, among other various organizations based on performance across 10 vaccination measures.
factors. GAO also interviewed 10 Additionally, Medicaid and managed care officials in five of the six states
stakeholder organizations, including described using data from other sources, such as Medicaid claims, to increase
those representing immunization COVID-19 vaccination rates among high-risk and vulnerable populations. For
managers and Medicaid directors. example, Medicaid officials in these states told us Medicaid claims data helped
them to identify and focus efforts on beneficiaries most at risk of adverse
outcomes from COVID-19. Although states reported using various strategies to
increase vaccinations, the effectiveness of their specific strategies is unclear due
View GAO-24-106526. For more information, to the nature of the COVID-19 public health emergency. According to Medicaid
contact Catina B. Latham at (202) 512-7114 or officials, it is difficult to attribute changes in Medicaid beneficiaries’ vaccination
lathamc@gao.gov. rates to a specific strategy, because the emergency required multiple concurrent
strategies.
United States Government Accountability Office
Contents
Letter 1
Background 6
Selected States Varied in Obtaining COVID-19 Vaccination Data;
System Interoperability Among Factors that Affected Data
Availability and Quality 10
Selected States Used COVID-19 Vaccination and Other Data to
Inform Vaccination Incentives and Outreach Efforts, but
Effectiveness of Individual Strategies is Unclear 22
Agency Comments 30
Appendix I Medicaid Program Changes to Support COVID-19 Vaccination
Activities 31
Appendix II Barriers to COVID-19 Vaccination and Strategies to Address Them 32
Appendix III GAO Contact and Staff Acknowledgments 35
Related GAO Products 36
Tables
Table 1: Selected State Medicaid COVID-19 Vaccination Incentive
Programs for Managed Care Organizations 23
Table 2: Examples of Medicaid Program Changes to Respond to
the COVID-19 Public Health Emergency 31
Table 3: Examples of Strategies to Improve COVID-19
Vaccination Rates Used by Medicaid Programs in Six
Selected States 33
Figures
Figure 1: Example of Routine Immunization Data Exchange with
Immunization Information Systems 8
Figure 2: COVID-19 Vaccination Data Exchange Scenarios 12
Page i GAO-24-106526 Medicaid COVID-19 Vaccination Data
Abbreviations
CDC Centers for Disease Control and Prevention
CMS Centers for Medicare & Medicaid Services
HHS Department of Health and Human Services
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Page ii GAO-24-106526 Medicaid COVID-19 Vaccination Data
Letter
441 G St. N.W.
Washington, DC 20548
April 18, 2024
The Honorable Ron Wyden
Chair
Committee on Finance
United States Senate
The Honorable Robert P. Casey, Jr.
Chairman
Special Committee on Aging
United States Senate
Vaccination efforts were a critical and complex part of the response to the
COVID-19 public health emergency. According to the Centers for Disease
Control and Prevention (CDC), an estimated 81 percent of the U.S.
population, or about 270 million people, received at least one dose of the
COVID-19 vaccination as of May 11, 2023. 1 Yet, the public health
emergency also highlighted disparities in vaccination rates among certain
populations, including low-income and medically needy populations with
health coverage provided by Medicaid, according to some sources. For
example, a December 2021 publication noted that estimated COVID-19
vaccination rates for Medicaid beneficiaries in some states averaged 15
percent to 20 percent lower than estimates for people enrolled with other
1On January 31, 2020, the Secretary of Health and Human Services declared a public
health emergency for the United States, retroactive to January 27, 2020, and ended the
public health emergency on May 11, 2023. The data represents CDC’s reporting of
COVID-19 vaccine administration for at least one dose of COVID-19 vaccine as of May
11, 2023. The CDC is an agency within the Department of Health and Human Services.
Page 1 GAO-24-106526 Medicaid COVID-19 Vaccination Data
forms of health coverage. 2 Medicaid beneficiaries may have complex
needs that could lead to poorer health outcomes due to COVID-19. 3
Given the importance of COVID-19 vaccinations in preventing severe
outcomes, such as hospitalizations and deaths, ensuring that Medicaid
beneficiaries receive the vaccine is important. However, state Medicaid
programs did not always have information on the vaccination status of
their beneficiaries during the COVID-19 public health emergency. Health
insurance claims did not fully capture information on COVID-19
vaccinations administered. 4 This was, in part, because COVID-19
vaccinations were purchased and distributed by the federal government
free of charge during the COVID-19 public health emergency. 5
When vaccinations for COVID-19 became available in December 2020,
the federal government required providers administering them to report
relevant information, such as the individuals vaccinated, to immunization
2See Rebecca Cooper et al., “Strategies to Increase COVID-19 Vaccination Rates in
Medicaid Enrollees: Considerations for State Leaders,” The National Academy for State
Health Policy and Duke University, Margolis Center for Health Policy (2021). See also
Sandhya Raman, “Medicaid Beneficiaries Less Likely to Get COVID-19 Shots,” Roll Call,
(June 30, 2021); and Phil Galewitz, “Medicaid Vaccination Rates Founder as States
Struggle to Immunize Their Poorest Residents,” PBS (Sept. 2, 2021).
3For example, according to a December 2022 analysis by the Medicaid and CHIP
Payment and Access Commission, Medicaid beneficiaries are more likely to report having
certain conditions, such as asthma, compared to individuals with private insurance (18.6
percent and 13.8 percent, respectively), and having fair or poor health (24.1 percent
compared to 7.3 percent, respectively). See the Medicaid and CHIP Payment and Access
Commission, “MACStats: Medicaid and CHIP Data Book” (Washington, D.C.: December
2022).
4For example, using data as of June 4, 2021, the Centers for Medicare & Medicaid
Services (CMS) estimated the agency had a claim for about half of vaccinated Medicare
beneficiaries, noting that was because many providers had administered vaccinations free
of charge and did not submit claims to bill for that service. See Centers for Medicare &
Medicaid Services, “Assessing the Completeness Of Medicare Claims Data For
Measuring COVID-19 Vaccine Administration,” accessed January 11, 2024,
https://www.cms.gov/data-research/cms-covid-19-data-products/medicare-covid-19-vaccin
e-analysis. See also Karen L. Schneider et al., “Use of Immunization Information Systems
in Ascertainment of COVID-19 Vaccinations for Claims-Based Vaccine Safety and
Effectiveness Studies,” JAMA Network Open, vol. 6, no. 5 (2023).
5CDC’s COVID-19 Vaccination Program ended as of October 3, 2023. However, most
Medicaid beneficiaries continue to be eligible for the COVID-19 vaccination free of cost
sharing. For example, Medicaid programs are required to cover and pay for COVID-19
vaccinations through September 30, 2024. Additionally, as of October 1, 2023, Medicaid
programs are required to cover and pay for all vaccinations recommended by the Advisory
Committee on Immunization Practices for most adult Medicaid beneficiaries, which
includes the COVID-19 vaccination.
Page 2 GAO-24-106526 Medicaid COVID-19 Vaccination Data
information systems. As a result, immunization information systems
became a primary source of data for tracking COVID-19 vaccination rates
and vaccination rate disparities—including among Medicaid
beneficiaries—and for directing resources to help increase vaccination
rates. 6 These immunization information systems are primarily operated by
states, with support from CDC, and their capabilities and data vary for a
variety of reasons, including differences in state laws. 7 Prior to the
COVID-19 public health emergency, immunization information systems
helped states and other entities track vaccination coverage in order to
identify populations at risk of acquiring vaccine-preventable diseases,
such as measles or influenza, and to respond to outbreaks. The scale of
the COVID-19 vaccination effort highlighted existing challenges with
immunization information systems, as well as questions about the
completeness of the COVID-19 vaccination data they received. 8
You asked us to examine Medicaid programs’ access to and use of data
from immunization information systems to improve COVID-19 vaccination
rates among beneficiaries, and factors contributing to immunization data
completeness. In this report we describe
1. the extent to which selected states’ Medicaid programs obtained
COVID-19 vaccination data through immunization information
systems, and any factors that affected data availability and quality;
and
2. how data from immunization information systems helped inform
strategies by selected states’ Medicaid programs to improve COVID-
19 vaccination rates, and information on the effectiveness of such
strategies.
To describe the extent to which selected states’ Medicaid programs
obtained COVID-19 vaccination data through immunization information
systems, and which factors affected data availability and quality, we
6As of October 6, 2023, when COVID-19 vaccinations became available for purchase on
the commercial market, CDC could no longer require providers to report COVID-19
vaccination administration information to immunization information systems.
7For example, according to the National Council of State Legislatures, 25 of 60 state and
other jurisdictions (e.g., territories that submitted their policies to CDC) require that all
providers report adult immunizations, and 28 jurisdictions have a reporting requirement in
place that may vary based on vaccine provider, age of patient, type of vaccine or specific
circumstance, such as a declared public health emergency.
8See Congressional Research Service, Immunization Information System: Overview and
Current Issues (Washington, D.C.: Feb. 1, 2022).
Page 3 GAO-24-106526 Medicaid COVID-19 Vaccination Data
reviewed relevant laws, regulations, and guidance. This included CDC
guidance on immunization information systems and requirements for
reporting COVID-19 vaccination data. We interviewed officials from CDC
and the Centers for Medicare & Medicaid Services (CMS) regarding
efforts supporting COVID-19 vaccination data sharing between Medicaid
and public health entities, as well as vaccination data quality. 9 We also
reviewed documentation and conducted interviews with Medicaid and
public health officials in a non-generalizable sample of six states
(California, Connecticut, Georgia, Idaho, Maryland, and Michigan).
We selected the non-generalizable sample of six states based on
variation across several criteria, including
• the share of adults residing in the state captured in the immunization
information system as of December 2020 and 2021, as a proxy for
data availability, based on CDC’s Immunization Information System
Annual Report;
• state per-capita COVID-19 vaccination rates showing the proportion of
individuals who had completed a vaccination series as of March 29,
2023, from CDC’s COVID-19 Data Tracker; and
• whether state immunization information systems shared data with
their Medicaid programs, as reported by the Association of
Immunization Managers’ 2019 Annual Survey. 10
In selecting states, we also considered variation in different Medicaid
program characteristics that could affect state Medicaid programs’
experiences using data. These characteristics included the state’s service
delivery model (i.e., managed care or fee-for-service), Medicaid
enrollment size, racial and ethnic distribution of the non-elderly Medicaid
population, and Medicaid expansion status. 11
9CMS is an agency within the Department of Health and Human Services.
10The Association of Immunization Managers’ survey captures responses from state
immunization program managers on “whether the immunization information system and
Medicaid share data and/or Medicaid uses the immunization information system for
reporting,” but does not describe the type or frequency of sharing that occurs.
11States may provide Medicaid services under a managed care model, a fee-for-service
model, or both. Under managed care, states pay managed care plans capitation
payments, which are fixed periodic payments typically paid on a per enrolled Medicaid
beneficiary basis. In turn, the managed care plans are responsible for paying providers for
the services delivered to enrolled beneficiaries. Under fee-for-service, states make
payments directly to providers for services provided.
Page 4 GAO-24-106526 Medicaid COVID-19 Vaccination Data
In each of the six states, we reviewed relevant state laws and data use
agreements, and interviewed state public health and Medicaid officials to
understand the collection and sharing of immunization data before,
during, and after the COVID-19 public health emergency. We also
interviewed state public health and Medicaid officials regarding factors
affecting immunization data collection, data sharing, and data quality. We
also interviewed the health information exchange organization in
Maryland, as it played a role in the exchange of immunization data
between the state’s immunization information system and its Medicaid
program. 12 In addition, we interviewed officials at the Department of
Health and Human Services’ (HHS) Office of the National Coordinator for
Health Information Technology to understand federal efforts related to
data sharing, such as interoperability between immunization information
systems and other health systems. We also interviewed officials from a
non-generalizable sample of 10 stakeholder organizations, and reviewed
reports, surveys, and fact sheets they developed. 13
To describe how data from immunization information systems helped
inform strategies selected states’ Medicaid programs used to improve
COVID-19 vaccination rates, and information on the effectiveness of such
strategies, we reviewed relevant federal guidance and state policies. For
example, we reviewed CMS guidance describing flexibilities available to
state Medicaid programs to respond to the COVID-19 public health
emergency and strategies for increasing COVID-19 vaccination rates
12Health information exchange organizations are organizations that electronically move
data among health care stakeholders, such as laboratories, public health departments,
hospitals, and physicians. Some states have one or more health information exchange
organizations that facilitate health information exchange statewide or for specific areas of
a state. A health information exchange organization may also facilitate exchange for
multiple states in a region of the country.
13We interviewed officials from the following stakeholder organizations: AcademyHealth,
American Immunization Registry Association, Association of Immunization Managers, the
Association of State and Territorial Health Officials, Civitas Networks for Health, Duke
Margolis Center for Health Policy, Medicaid and CHIP Payment and Access Commission,
National Association for State Health Policy, National Association of County and City
Health Officials, and the National Association of Medicaid Directors. We selected these
organizations due to their familiarity with immunization information systems, vaccination
data sharing between Medicaid and public health agencies, vaccination strategies, or
because they had published research in this area. When characterizing the responses
made by these organizations, we used the term “some” when mentioned by fewer than
five stakeholders.
Page 5 GAO-24-106526 Medicaid COVID-19 Vaccination Data
among the general population, including Medicaid beneficiaries. 14 We
also reviewed CDC guidance on barriers to vaccination and strategies for
increasing access to and receipt of recommended vaccinations, including
among vulnerable populations. 15 We also reviewed relevant state policies
and other documentation, and interviewed Medicaid officials in the six
selected states about the strategies they used to increase COVID-19
vaccination rates, including among vulnerable and high-risk populations,
and information on their effectiveness. We also reviewed documentation
and interviewed officials from the largest Medicaid managed care
organization, based on enrollment, in the four selected states with this
type of delivery system (California, Georgia, Maryland, and Michigan), as
well as officials with Connecticut’s medical administrative services
organization, which provides administrative services to support the state
Medicaid program in processing provider claims. Also, to better
understand strategies to improve COVID-19 vaccination rates and their
effectiveness, we interviewed officials from 10 stakeholder organizations,
and reviewed articles identified from a search of various databases such
as Scopus, ProQuest Health & Medical Collection, MEDLINE, and
ProQuest COVID-19 Research. 16
We conducted this performance audit from January 2023 to April 2024 in
accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
Immunization information systems play a vital role in public health
Background officials’ efforts to monitor vaccination coverage for routine vaccinations
and to identify areas of low vaccination, which may be more likely to
14See appendix I for information on flexibilities that were available to state Medicaid
programs during the public health emergency to support them in their efforts to ensure
beneficiaries had access to COVID-19 vaccinations.
15See appendix II for information on barriers to COVID-19 vaccination and strategies for
addressing them, including strategies used by the six selected state Medicaid programs to
increase vaccination rates that were not informed by data from immunization information
systems.
16Our literature search covered scholarly articles, conference papers, government reports,
and non-profit materials published from 2020 to 2023. Through this review, we identified
12 articles that contained information on barriers and strategies to improve COVID-19
vaccination rates more broadly.
Page 6 GAO-24-106526 Medicaid COVID-19 Vaccination Data
experience outbreaks of vaccine-preventable diseases, such as measles
and influenza. Immunization information systems collect a variety of
information on vaccines administered, such as the name and date of birth
for individuals who received a vaccine, and the type of vaccination
administered. State public health departments initially developed
immunization information systems to capture routine childhood
vaccinations, but many states use them to collect information on
vaccinations administered to adults as well. 17
In general, state policies govern provider reporting requirements and data
sharing, and those policies vary by state. 18 For instance, state policies
may vary in terms of the type of providers required to report immunization
data, and in the consent policies that allow immunization information
systems to collect and store patients’ vaccination records. 19 In addition,
state policies may determine whether immunization information systems
share or exchange patient-level data—that is, the individual immunization
records recorded for each patient that contain identifiable demographic
information—with other entities, including other jurisdictions or state
agencies.
Specifically, depending on the state, immunization information systems
may share patient-level vaccination data with
17For example, as of 2020, these systems were estimated to capture immunization data
for 68 percent of adults, nationally, compared to 84 percent of 11- to 17-year-olds, and 94
percent of less than 6-year-olds. See Centers for Disease Control and Prevention, “2020
IISAR Data Participation Rates,” accessed January 29, 2024,
https://archive.cdc.gov/#/details?url=https://www.cdc.gov/vaccines/programs/iis/annual-re
port-iisar/2020-data.html. More recent estimates indicate increases in the percentage of
adults captured in immunization information systems since the start of the COVID-19
public health emergency. For example, adult participation data as of 2022 indicate
immunization data are captured for 94 percent of adults, nationally.
18COVID-19 vaccination reporting differed substantially during the public health
emergency. Specifically, to be permitted to administer the COVID-19 vaccination through
CDC’s COVID-19 Vaccination Program, CDC required providers to report information
about vaccinated individuals. Additionally, similar to routine immunization data, CDC
encouraged providers to report demographic information about vaccinated individuals,
such as race and ethnicity, to immunization information systems to assist with vaccination
monitoring efforts during the COVID-19 public health emergency.
19According to stakeholders and for the purposes of this report, state patient consent
policies are policies in certain states that may allow patients the right to opt-out of or opt-in
to sharing their vaccination data with the immunization system (i.e., remove or exclude
vaccination data in the immunization information system).
Page 7 GAO-24-106526 Medicaid COVID-19 Vaccination Data
• providers to help them ensure that their patients are up-to-date on
their vaccinations,
• patients to help them manage their health care, and
• health plans or state Medicaid agencies to help support quality
improvement efforts. 20
In situations where identifiable data are not necessary or permitted to be
shared, immunization information systems may instead share de-
identified or aggregate data, such as the vaccination rate for a given area
or population. This type of data may be reported to CDC or included as
part of public data dashboards to support routine vaccination efforts or
disease surveillance activities, as was the case during the COVID-19
public health emergency. (See fig. 1.)
Figure 1: Example of Routine Immunization Data Exchange with Immunization Information Systems
20As part of its responsibility to oversee states’ efforts to ensure the quality of services
provided to Medicaid beneficiaries, CMS collects, assesses, and reports on standardized
measures of quality of care. CMS does this primarily through the Child and Adult Core
Sets, which include quality measures related to primary and preventive care, behavioral
health care, and patients’ experiences of care. For example, states may report on the
percentage of children in the Medicaid program that are up-to-date on their immunizations.
States report measure results to CMS annually, and while state reporting had been
voluntary, reporting for most measures became mandatory in fiscal year 2024.
Page 8 GAO-24-106526 Medicaid COVID-19 Vaccination Data
Although states are responsible for maintaining their immunization
information systems, CDC provides funding and technical assistance to
support system infrastructure, data storage and sharing, as well as
workforce support. 21 CDC also develops functional standards for the
various operations, data quality, and technological capabilities for
immunization information systems. CDC encourages states to adopt the
functional standards, but states can implement or customize them. For
example, CDC’s functional standards suggest that immunization
information systems be capable of sharing data with other health
systems, but a state has flexibility in determining how to implement data
sharing. 22 CDC also encourages, but does not require, states to collect
certain data elements in their immunization information systems, such as
race or ethnicity when reporting routine vaccination data.
21While CDC does not have a dedicated source of funding for immunization information
systems, the following CDC programs and cooperative agreements, among others, can be
used to support immunization information systems: the Epidemiology and Laboratory
Capacity for Prevention and Control of Emerging Infectious Diseases Program, Section
317 Immunization Program funding, and the Vaccines for Children Program. During the
COVID-19 public health emergency, CDC provided $3 billion in supplemental funding to
support various vaccination-related activities, including expanding the existing
immunization information system infrastructure.
22For instance, a state may choose to implement one-way sharing, which allows the
immunization information system only to receive vaccination data, or two-way (i.e.,
bidirectional) sharing, which also allows the immunization information system to send as
well as receive vaccination data from the other organization.
Page 9 GAO-24-106526 Medicaid COVID-19 Vaccination Data
Selected States
Varied in Obtaining
COVID-19
Vaccination Data;
System
Interoperability
Among Factors that
Affected Data
Availability and
Quality
Four of Six Selected Medicaid programs in our six selected states varied in their ability to
States’ Medicaid Programs obtain patient-level COVID-19 vaccination data from state immunization
information systems. Specifically, the Medicaid programs in four of the six
Obtained Patient-Level
states (California, Georgia, Maryland, and Michigan) obtained patient-
COVID-19 Vaccination level COVID-19 vaccination data from their state immunization
Data from Immunization information systems during the public health emergency. Prior to the
Information Systems COVID-19 public health emergency, officials in these four states reported
During the Public Health having laws that authorized their Medicaid programs to obtain
immunization data from the public health department.
Emergency
In addition, the processes for exchanging patient-level COVID-19
vaccination data between immunization information systems and the
Medicaid programs varied among the four states. (See fig. 2.) For
example, in Maryland, the state health information exchange organization
helped facilitate the exchange, while in California and Michigan these
organizations were not part of the process. 23 Specifically, Maryland’s
health information exchange organization gathered and compiled data
from different sources, such as hospitals, Medicaid, and the immunization
information system, into a database that the state public health
department and Medicaid could query to retrieve information on the
vaccination status of certain individuals. Additionally, the four states
23While Georgia’s health information exchange organization did not facilitate the
exchange of COVID-19 vaccination data between the state public health department and
Medicaid, Georgia Medicaid officials told us the health information exchange organization
shared any hospital or provider records that contained data related to COVID-19 with both
departments to help them to supplement their records.
Page 10 GAO-24-106526 Medicaid COVID-19 Vaccination Data
varied in whether the Medicaid program had the ability to query
immunization data directly or needed assistance from the state public
health department in order to match beneficiary files with data from the
immunization information system. For example:
• California public health officials told us the state Medicaid program
provided their department with files listing Medicaid beneficiaries,
which public health officials then matched to immunization data from
their own system before sending files back with immunization records
added.
• Georgia Medicaid officials told us the state public health department
provided the state Medicaid program files containing all immunization
records, which they then matched to Medicaid beneficiary records.
• Maryland and Michigan officials told us they were able to identify
Medicaid beneficiaries’ immunization records in a repository that
merged data from the immunization information system and other
data sources operated by the health information exchange
organization or the state health department, respectively.
Page 11 GAO-24-106526 Medicaid COVID-19 Vaccination Data
Figure 2: COVID-19 Vaccination Data Exchange Scenarios
Note: This figure depicts two examples of the exchange of COVID-19 vaccination data exchange
between state immunization information systems and Medicaid programs during the COVID-19 public
health emergency.
Page 12 GAO-24-106526 Medicaid COVID-19 Vaccination Data
Medicaid or public health officials from California, Georgia, and Maryland
also noted their Medicaid programs and state public health departments
exchanged COVID-19 vaccination data more often than they had
exchanged routine vaccination data prior to the COVID-19 public health
emergency. For example, Medicaid and public health officials from
Georgia and Maryland said they shared COVID-19 data weekly, while
they shared routine vaccination (e.g., influenza, measles) data less
frequently or as needed. 24
In contrast, Medicaid programs in the remaining two selected states
(Connecticut and Idaho) did not obtain patient-level COVID-19
vaccination data from their state immunization information systems.
• In Connecticut, state Medicaid and public health officials said the state
regulation in effect prior to the COVID-19 public health emergency did
not specify Medicaid as an authorized user; thus, the Medicaid
program did not obtain vaccination data from the immunization
information system. Although a new state law enacted in July 2022
expanded the types of entities explicitly permitted access to
immunization data, Medicaid and state public health officials told us
the issue of Medicaid’s access to the data was not resolved by the
end of the COVID-19 public health emergency. 25
• In Idaho, Medicaid officials told us that by state law their agency did
not have access to patient-level vaccination data, but obtained
aggregate COVID-19 vaccination data for adults from the
immunization information system. 26 Using these data, Medicaid
officials told us they were able to assess the extent to which Medicaid
claims data reflected vaccination information for beneficiaries. As a
result, they told us they were confident that Medicaid claims data
24Routine vaccinations are those recommended for adults, adolescents, and children in
the United States, depending on age and vaccine history. Routine vaccinations could
include vaccines for influenza, measles, mumps, or other vaccine preventable diseases.
25Because of the change to Connecticut law, public health officials told us they were
working to amend their data use agreement to enable them to share patient-level
vaccination data with the Medicaid program. See Connecticut House Bill 5506 § 493, Pub.
Act No. 22-118 (2022); CONN. GEN. STAT. ANN. § 19a-25 (2022).
26According to public health officials, Idaho state law does not allow the sharing of patient-
level vaccination data for children from the immunization information system, including
with the Medicaid program. The statute prohibits sharing patient-level information about
children with any entity not named in statute. Aggregate data for children can be provided
and de-identified information may be shared for adults 18 years and older. See ID. CODE
ANN. § 39-4803 (2023).
Page 13 GAO-24-106526 Medicaid COVID-19 Vaccination Data
accurately reflected information on vaccinated and unvaccinated adult
beneficiaries during the COVID-19 public health emergency.
Selected States and State officials and stakeholders we interviewed described factors that
Stakeholders Described affected the availability and quality of COVID-19 vaccination data during
the public health emergency, including for Medicaid programs. These
How Interoperability Gaps
factors had the potential to make the vaccination data Medicaid programs
and Other Factors received from immunization information systems less usable or reliable
Affected COVID-19 when integrated into their data. Public health officials in some of the six
Vaccination Data selected states also provided examples of how they addressed
Availability and Quality, challenges as the COVID-19 public health emergency progressed.
Including for Medicaid Interoperability gaps between systems. State Medicaid and public
Programs health officials from three of the four selected states that exchanged
COVID-19 vaccination data between Medicaid and their state
immunization information system (California, Georgia, and Michigan)
indicated that gaps in interoperability between older immunization
information systems and Medicaid systems affected the availability of
timely and complete vaccination data. 27 Furthermore, according to some
selected stakeholders, such as the American Immunization Registry
Association and the Association of Immunization Managers, challenges in
capturing COVID-19 vaccination data highlighted longstanding concerns
about interoperability and data sharing between aging immunization
information systems and other data systems. 28
Public health or Medicaid officials from three states (California, Georgia,
and Michigan) told us they had difficulty merging information from
Medicaid and public health sources, in part, because there are very few
data fields that are collected by both immunization information systems
and Medicaid programs due to the different needs of each program. For
27Conversely, Maryland officials told us that they did not have difficulty merging
information from Medicaid and public health sources because the state health information
exchange had the capability to consolidate data from different sources.
28See American Immunization Registry Association, Talking Points for IIS Regarding
COVID-19 Data Quality (Washington, D.C.: Feb. 19, 2021); and Association of
Immunization Managers, Collaborating with Medicaid: Immunization Programs
Observations (Rockville, Md.: July 30, 2021). Our prior work has also highlighted similar
challenges and concerns around interoperability in health information technology systems.
In June 2022, we reported state public health officials most often identified gaps in
interoperability among state systems as one of their top challenges related to the
management of public health information during the public health emergency. See GAO,
COVID-19: Pandemic Lessons Highlight Need for Public Health Situational Awareness
Network, GAO-22-104600 (Washington, D.C.: June 23, 2022).
Page 14 GAO-24-106526 Medicaid COVID-19 Vaccination Data
example, immunization information systems generally track vaccination
coverage and outbreak surveillance; however, Medicaid systems are
used to manage Medicaid patients’ care and bill for services. Public
health officials in Michigan told us that their inability to automate the
process of merging Medicaid and public health data meant staff manually
conducted data pulls, shared data, and matched patient records, which
increased the burden on staff and led to human error.
Medicaid Enterprise Systems Funding Moreover, they noted that COVID-19 supplemental funding from CDC
Centers for Medicare & Medicaid Services’ supported upkeep of the state’s aging immunization information system,
(CMS) Medicaid Enterprise Systems funding but did not enable them to fully modernize it.
may be used to support state Medicaid
programs’ information technology systems.
This funding is available for a range of To counter interoperability challenges and improve data access, state
technology-related system activities, including
developing and implementing technology public health and state Medicaid officials in these three selected states
supporting immunization information systems, described using data use agreements to outline the formats for
as well as the maintenance and operations of exchanging data. These data use agreements specifically outline the data
these systems.
Specifically, state Medicaid programs may
elements that are exchanged and the formats for doing so. Additionally,
request approval to receive an enhanced public health officials in California shared that they planned to seek CMS
federal matching rate of 90 percent (i.e., $90 Medicaid Enterprise System funding to help improve their ability to match
in federal funds for every $10 spent by the
state) for the design, development, and immunization information system data with Medicaid records in the future
implementation of their proposed project. To and are considering a unique Medicaid identifier to improve their ability to
obtain approval, CMS requires states to
submit planning documentation that outlines
match data between Medicaid and public health systems. 29
project goals and an implementation timeline.
According to CMS officials, these plans
undergo a review to determine if the projects
Public health officials in our selected states also described varying
meet specific criteria—such as, seamless degrees of participation in CDC’s Immunization Gateway during the
coordination and integration between COVID-19 public health emergency. CDC developed the Immunization
systems—and will demonstrate measurable
outcomes and improvements to the state Gateway—a data system intended to facilitate vaccination data exchange
Medicaid program. State Medicaid programs both among states and between federal agencies (e.g., Department of
may also request a 75 percent enhanced
matching rate to support ongoing operations
Veterans Affairs) and states—in part to help address interoperability
of CMS-approved systems. challenges related to the exchange of information across these different
Source: CMS documentation. | GAO-24-106526
29In addition to Medicaid Enterprise System funding, Helios—a jointly funded effort by
CDC and the Office of the National Coordinator for Health Information Technology to use
data exchange standards to promote more flexible and effective data exchanges between
public health departments and other entities—may make it easier to leverage and share
vaccination data in immunization information systems. According to CDC officials, as the
standards developed through Helios mature, state Medicaid programs, where permitted,
will have access to modern methods for receiving the immunization histories of their
covered patients. In addition to Helios, CDC officials said they continue to support efforts
to improve the quality and completeness of vaccination data collected in immunization
information systems. According to CDC’s congressional budget justification for fiscal year
2024, the agency requested $1.2 billion to support its Immunization and Respiratory
Diseases Program to fund several activities, including continued efforts to modernize
immunization information systems.
Page 15 GAO-24-106526 Medicaid COVID-19 Vaccination Data
systems. 30 Three states (Connecticut, Maryland, and Michigan) used the
Immunization Gateway to exchange immunization data with some other
states during the COVID-19 public health emergency, but also used other
state-to-state data sharing arrangements, according to state public health
officials. 31 For example, Maryland officials reported they established a
connection through the Immunization Gateway with the District of
Columbia, which allowed them to add information to the state
immunization information system on more than 225,000 COVID-19 doses
administered to Maryland residents. The remaining three selected states
(California, Georgia, and Idaho) either did not exchange data with other
states using the Immunization Gateway during the COVID-19 public
health emergency or could not exchange immunization data with other
states due to state level policies restricting such exchange. 32
Patient matching. In three of the four selected states that exchanged
patient-level vaccination data (Georgia, Maryland, and Michigan) between
their state immunization information system and Medicaid, Medicaid and
public health officials identified challenges matching patient vaccination
records with Medicaid records, which is necessary to determine if the
30For example, when a patient crosses jurisdictional borders to receive a vaccination, their
vaccination record is reported to the state where the vaccine was administered. Unless
the record is subsequently shared with and integrated into the patient’s home state’s
immunization information system, that state will have missing data, as would any
downstream users of the data, such as Medicaid.
According to CDC officials, as of February 2023, most jurisdictions with immunization
information systems planned to participate in the Immunization Gateway, which became
operational in October 2021, with almost half having exchanged data with at least one
other immunization information system.
31In Connecticut, state public health officials told us that although the ability to share data
with the Medicaid program was unclear, state law in effect prior to May 2022 permitted the
state immunization information system to share data with federal partners and other
states’ immunization information systems. Thus, according to officials, data sharing
through the Immunization Gateway was also permitted.
32Five of the six selected states also reported using the Immunization Gateway to obtain
immunization data from the Department of Veterans Affairs during some of the COVID-19
public health emergency. States began exchanging through the Immunization Gateway at
different times with different entities. Establishing a connection through the Immunization
Gateway can take time and resources, according to public health officials in two selected
states. Michigan officials reported other barriers to fully utilizing the Immunization
Gateway, including earlier during the public health emergency, such as the readiness of
other states to connect to it.
Page 16 GAO-24-106526 Medicaid COVID-19 Vaccination Data
records refer to the same patient. 33 According to Georgia Medicaid
officials, patient matching errors meant that the program lacked
information on some Medicaid patients’ COVID-19 vaccinations, so
vaccination rates appeared lower than they were. Public health officials in
Michigan said that the COVID-19 vaccine rollout caused an
unprecedented number of duplicate records in Michigan’s immunization
information system, which they were able to resolve. Additionally, officials
noted they have multiple ongoing data modernization efforts that include
updates to the algorithms and processes they use to conduct patient
matching, which will further improve accuracy and data quality. 34
Volume of data. The increase in reporting volume associated with the
COVID-19 public health emergency overwhelmed the capacity of
immunization information systems to capture vaccination records when
COVID-19 vaccines first became available, according to public health
officials in two selected states (California and Idaho) and some
stakeholders we interviewed. For example, public health officials in
California noted they went from receiving up to 800,000 messages daily—
that is, vaccination records and queries requesting an individual’s
vaccination status—before the COVID-19 public health emergency to 4
million such messages during the public health emergency. According to
the officials, the outdated immunization information system was initially
unable to capture and store the large volume of vaccination data
received. As a result, the state stored vaccination data in a cloud-based
system until the public health department could build capacity in its
immunization information system.
In contrast, officials in Maryland told us they did not encounter capacity
challenges, because they relied on the state health information exchange
organization—which had sufficient capacity—to lead their COVID-19 data
collection effort. According to officials at the state’s health information
exchange, the immunization information system received tens of
thousands of submissions each day, which would not have been feasible
33Patient matching generally relies on the use of demographic information such as a
patient’s name, date of birth, sex, Social Security number, or address, among other
information. Officials from California, Georgia, and Michigan told us they used a process
known as probabilistic matching when merging data from immunization information
systems and Medicaid. Probabilistic matching is an analysis to determine the overall
likelihood that two records are matches.
34The challenges of patient matching are not unique to the COVID-19 public health
emergency. See GAO-23-105540; and GAO, Health Information Technology: Approaches
and Challenges to Electronically Matching Patients’ Records across Providers,
GAO-19-197 (Washington, D.C.: Jan. 15, 2019).
Page 17 GAO-24-106526 Medicaid COVID-19 Vaccination Data
for the immunization information system to handle. As a result, state
public health and Medicaid officials said they created processes to direct
immunization submissions through the state’s health information
exchange organization instead, which was accustomed to processing
large volumes of data prior to the public health emergency.
Inconsistent data capture. The large influx of new users submitting
vaccination data to immunization information systems also created
inconsistencies and challenges with the quality of vaccination data,
according to three selected states (Connecticut, Georgia, and Michigan),
and other reports. 35 For instance, providers approved to administer the
vaccination, such as paramedics and medical and nursing students, may
not have had prior experience submitting vaccination data to the
immunization information system, because they were not previously
required to do so. For example, among our selected states,
• Michigan public health officials said that members of the National
Guard helped enter data into the immunization information system,
but their lack of familiarity with the system led to errors.
• Georgia public health officials told us that records for some individuals
vaccinated at a mass vaccination site had the same date of birth,
which they believed to be incorrect as the date was also the default
date for the field. This made it challenging to match these data to the
state’s vaccination records.
Additionally, as we reported in March 2021, several factors contributed to
missing information on race and ethnicity in immunization information
systems’ COVID-19 vaccination records early in the COVID-19 vaccine
rollout. 36 Contributing factors included the lack of consistent collection and
reporting of this information by providers, and patient refusal to provide
35For example, according to the HHS Office of the Inspector General, state immunization
programs experienced challenges obtaining timely and complete vaccine administration
data from providers, which they attributed to having limited resources to sufficiently train
providers on how to use their data systems, including how to input data in the data
systems (e.g., immunization information systems) in a timely and accurate way. Further,
state immunization program officials reported that the immunization information system
onboarding process was particularly challenging and burdensome when some providers
had minimal to no prior vaccine experience. See Department of Health and Human
Services, Office of the Inspector General, Early Challenges Highlight Areas for
Improvement in COVID-19 Vaccination Programs, OEI-04-21-00190 (Washington, D.C.:
Jan. 31, 2023).
36Specifically, data collected from states and jurisdictions on race and ethnicity for COVID-
19 vaccine recipients as of March 8, 2021, were missing for almost half (46.7 percent) of
recipients who received at least one dose. See GAO-21-387.
Page 18 GAO-24-106526 Medicaid COVID-19 Vaccination Data
the information, according to CDC officials and stakeholders. 37 These
challenges affected the quality of race and ethnicity data available in
immunization information systems, but did not affect Medicaid programs’
data in our selected states, according to our review. Medicaid officials we
interviewed said they generally relied on their own demographic data.
Specifically, Medicaid officials in California, Georgia, Maryland, and
Michigan told us that when demographic data (e.g., race or ethnicity)
differs between Medicaid and the immunization information system, they
use Medicaid data (e.g., from Medicaid enrollment data). Medicaid
officials in some selected states said they have found their demographic
data to be more reliable than that captured by the immunization
information system. 38
Selected States and State and federal officials we interviewed underscored that, following the
Federal Officials Identified COVID-19 public health emergency, state policies remain important
drivers of vaccination data availability. That is, in part, because the
State Policies as
federal requirement for reporting COVID-19 vaccinations to immunization
Continuing to Influence information systems—which increased the availability of vaccination data
Vaccination Data Available that could be shared by public health departments with other entities,
to Medicaid Programs such as Medicaid programs—is no longer in effect. 39
After the Public Health
More specifically, officials from four of the six selected states (California,
Emergency Connecticut, Georgia, and Maryland) told us their state policies continue
37CDC reported steps it took to work with states to improve demographic data
completeness, including sending weekly data quality reports to jurisdictions beginning in
February 2021. In April 2022, CDC reported that the percentage of COVID-19
vaccinations with known ethnicity had increased from 79 percent to 87 percent between
February and December of 2021.
38We and others have reported gaps in race and ethnicity data collected by state Medicaid
programs. For example, in April 2023, we reported that five of our six selected states had
unreliable data on the race and ethnicity of beneficiaries with intellectual and
developmental disabilities, limiting our ability to analyze the distribution of beneficiaries.
See GAO, Medicaid: Characteristics of and Expenditures for Adults with Intellectual or
Developmental Disabilities, GAO-23-105457 (Washington, D.C.: Apr. 24, 2023). See also
Medicaid and CHIP Payment and Access Commission, March 2023 Report to Congress
on Medicaid and CHIP (Washington D.C., March 2023). CMS is taking some steps to
improve Medicaid data quality. For example, CMS assesses the quality of race and
ethnicity data states collect through eligibility determinations and report to CMS’s
Transformed Medicaid Statistical Information System. The Transformed Medicaid
Statistical Information System captures a variety of data from state Medicaid programs to
support federal and state program management, financial management, and program
integrity activities.
39As previously noted, the federal requirement mandating providers administering COVID-
19 vaccinations to report COVID-19 vaccination data to immunization systems ended on
October 6, 2023, with the commercialization of the COVID-19 vaccine.
Page 19 GAO-24-106526 Medicaid COVID-19 Vaccination Data
to require providers to report all COVID-19 vaccination records to
immunization information systems following the conclusion of the COVID-
19 public health emergency. In contrast, officials from the remaining two
selected states (Idaho and Michigan) told us they have policies that only
require reporting by certain providers for children’s vaccines (which apply
to COVID-19 vaccinations for children, as well as to other types of
vaccinations for children). 40 Therefore, in these states providers are not
required to report on most COVID-19 vaccinations for adults. Officials
from both states said they continue to encourage providers to report
COVID-19 vaccinations for adults to the immunization information system
even though such reporting is no longer required. 41
Of the four selected states that require providers to submit vaccination
records for all age groups, officials from three states told us they
expanded their immunization reporting requirements—which apply to all
types of vaccinations—as a result of their experiences responding to the
COVID-19 public health emergency.
• Maryland expanded its immunization reporting requirements in April
2022 to include providers who were previously exempt from reporting
to the state’s immunization information system, such as those working
in nursing homes or long-term care facilities. 42 According to Medicaid
and public health officials, the state immunization information system
now requires reporting from all providers and health care settings for
all vaccinations.
• Connecticut enacted a state law in May 2022 requiring providers to
report all vaccinations, regardless of age, to the state immunization
40According to Idaho officials, providers participating in the Vaccine for Children program
are required to report vaccination administration data to the immunization information
system for all children through 18-years of age. In contrast, in Michigan, all providers are
required to report vaccinations administered to children 20-years of age or younger,
according to state documentation.
41Although some states do not have policies requiring providers to report routine
vaccination data for adults to the immunization information system, providers may choose
to do so. For example, CMS and the Office of the National Coordinator for Health
Information Technology have encouraged providers to report this information to
immunization information systems through the development of certification standards for
electronic health records, which was incentivized through the implementation of the Health
Information Technology for Economic and Clinical Health Act.
42See MD. CODE HEALTH - GEN §18–109(d)(6)(I)3 (2022).
Page 20 GAO-24-106526 Medicaid COVID-19 Vaccination Data
information system. 43 State officials told us that previously, providers
were only required to report vaccination data for children 7 years of
age and under. Additionally, as previously noted, this law permits the
public health department to share patient-level immunization and
other data with the Medicaid program, according to public health
officials.
• California enacted a state law requiring all providers beginning in
January 2023 to report all vaccinations for all age groups to the state
immunization information system. 44 According to public health
officials, this law also requires providers to report race and ethnicity
data and will help improve the quality of demographic information in
vaccination records.
Because these changes involve increased reporting requirements, they
should increase the amount of vaccination data captured going forward,
compared to what was reported before the public health emergency, as
well as what may be shared with Medicaid programs. However, public
health officials in California and Maryland also noted their requirements
do not include any specific enforcement mechanisms, which may make it
challenging to obtain immunization data from some providers. California
public health officials noted that the COVID-19 public health emergency
made them more aware of the various types of providers in the state that
administer vaccines, which will help the state ensure these providers
continue to report to the immunization information system, as required.
43See Connecticut House Bill 5506 § 493, Pub. Act No. 22-118 (2022); CONN. GEN. STAT.
ANN. § 19a-25 (2022).
44See California Assembly Bill 1797, (2021) codified at CAL. HEALTH SAFETY CODE §
120440 (2022).
Page 21 GAO-24-106526 Medicaid COVID-19 Vaccination Data
Selected States Used
COVID-19
Vaccination and Other
Data to Inform
Vaccination
Incentives and
Outreach Efforts, but
Effectiveness of
Individual Strategies
is Unclear
Selected States’ Medicaid Medicaid officials in our four selected states with access to patient-level
Programs Used Patient- COVID-19 vaccination data from immunization information systems
(California, Georgia, Maryland, and Michigan) described ways they used
Level COVID-19
those data during the public health emergency. For example, state
Vaccination Data for Medicaid officials in three of the four states described using patient-level
Vaccine Incentive Efforts vaccination data to implement two types of strategies: incentives and
and Targeted Outreach targeted outreach. 45 The strategies targeted different groups, such as
managed care organizations, providers, or Medicaid beneficiaries.
Vaccination Incentives State Medicaid officials in California, Maryland, and Michigan told us that
patient-level vaccination data helped them set COVID-19 vaccination
targets and financially reward managed care organizations that improved
vaccination rates. These states implemented incentive programs, with
various approaches, for managed care organizations to improve
vaccination rates, in cases when there was a lower than anticipated
vaccination rate. (See table 1.) For example, California developed its
incentive program because of disparities it identified in the vaccination
rate between Medicaid beneficiaries and the non-Medicaid population in
California. Specifically, California Medicaid reported that as of August 8,
2021, 48.7 percent of Medicaid beneficiaries aged 12 years and older had
received one COVID-19 vaccination dose, compared to 73.7 percent of all
45State Medicaid program and managed care organization officials described other
strategies they implemented that did not involve the use of patient-level COVID-19
vaccination data from immunization information systems. See appendix II for a description
of those strategies used.
Page 22 GAO-24-106526 Medicaid COVID-19 Vaccination Data
Californians of the same age group. 46 In response, the state’s incentive
program established vaccination targets to increase the overall
vaccination rate among Medicaid beneficiaries, as well as vaccination
rates within certain Medicaid subpopulations.
Table 1: Selected State Medicaid COVID-19 Vaccination Incentive Programs for Managed Care Organizations
Performance
State Description period Awards
California Program designed to increase first dosage of COVID-19 9/1/2021– $187.5 million to all 25 organizations,
vaccine among unvaccinated beneficiaries aged 12 years 2/28/2022 ranging between $24,800 and $45.1
and older. (6 months) million per organization.
Managed care organizations could earn full or partial
payments based on performance across 10 performance
measures, and for developing a vaccination response plan.
Measures focused on individuals by age group, as well as
certain vulnerable populations.a
Maryland Program designed to increase full COVID-19 vaccination 1/2022–3/2022 (3 $4 million to all nine organizations,
(one or two doses, depending upon the vaccine months) ranging between $105,600 and
manufacturer) among unvaccinated beneficiaries aged 12 $945,000 per organization.
years and older.
Managed care organizations received a fixed amount, $100
for each member vaccinated, within a set number of
members that varied by the organization’s enrollment size.
Michigan Program designed to increase first dosage of COVID-19 10/2020 – 9/2021 Fiscal year 2021: $0 awarded (no
vaccine among unvaccinated beneficiaries aged 16 years (fiscal year 2021) managed care organization met Tier 1
and older (fiscal year 2021) or 12 years and older (fiscal and or Tier 2 benchmarks).c
year 2022). 10/2021–9/2022 Fiscal year 2022: $53.9 million
Managed care organizations could earn payment for (fiscal year 2022) awarded to one of nine organizations.
reaching established vaccination benchmarks aligned with
the state public health department’s April 2021 vaccination
response plan:
• Tier 1: 55 percent of beneficiaries resulted in 30
percent of award.b
• Tier 2: 70 percent of beneficiaries resulted in 70
percent of award.
Source: GAO analysis of state documentation and interviews with state Medicaid officials. | GAO-24-106526
Note: State officials reported using different strategies to fund the incentive programs. California
Medicaid officials said they claimed a 50 percent federal match rate, and an additional 6.2 percent for
certain medical services that was available due to enhanced federal matching authorized under
federal law. Maryland Medicaid officials said they claimed the federal match rate of 50 percent for
administrative services. Michigan Medicaid officials said they claimed the federal match rate of 100
percent for COVID-19 vaccination administration that was available during the COVID-19 public
health emergency. Medicaid officials in each state noted that the total awards fell within the
46See State of California, Department of Health Care Services, “Medi-Cal COVID-19
Vaccination Incentive Program,” All Plan Letter 21-010 (Revised) (Sacramento, Calif.:
Mar. 7, 2022).
Page 23 GAO-24-106526 Medicaid COVID-19 Vaccination Data
permissible payment limit for Medicaid managed care for incentive payments (i.e., up to 5 percent
above the capitation payment).
a
For example, managed care organizations had to report on two of the following three measures:
percent of homebound beneficiaries who received at least one dose of a COVID-19 vaccine; percent
of beneficiaries 50-64 years old with one or more chronic conditions; and percent of primary care
providers who provided COVID-19 vaccines in their office. Additionally, two measures focused on
increasing vaccinations among the race and ethnicity groups with the lowest and second-lowest
baseline vaccination rates.
b
The award was based on an inventive pool funded by monies the state recouped from managed care
organizations that did not spend projected COVID-19 vaccination administration funding. Managed
care plans were also required to submit a vaccination response plan to be eligible for an award.
c
In fiscal year 2021, Michigan Medicaid officials said $40.4 million was recouped from managed care
organizations and returned to the federal government.
According to California Medicaid officials, their program resulted in
improvements to vaccination rates among Medicaid beneficiaries.
However, California Medicaid officials also said that disparities in
vaccination rates between Medicaid beneficiaries and the general
population remained. State officials indicated that these continuing
disparities may, in part, be related to the short time frame that the
incentive program was in effect (6 months), vaccination hesitancy, and
longstanding barriers, such as lack of transportation and difficulty taking
time off work, that Medicaid beneficiaries face in accessing vaccinations.
Officials in Maryland and Michigan indicated their programs had less of
an effect on COVID-19 vaccination rates than they had hoped, noting
similar reasons as California officials.
Selected managed care organizations in these three states also
developed incentive programs directed toward providers, beneficiaries, or
both. For example, according to Michigan Medicaid officials, all managed
care organizations offered provider incentives. Documentation for the
managed care organization in Michigan we interviewed indicated they
paid providers $10 to $100 per eligible beneficiary vaccinated, depending
on the overall vaccination rate for the provider’s eligible patients. 47
Additionally, most managed care organizations in all three states
(California, Maryland, and Michigan) offered beneficiaries incentives,
according to state officials. For example, California reimbursed 22 of its
25 managed care organizations because they opted to provide incentives
47Under this program, the managed care organization paid providers an incentive for each
eligible member that received at least one dose of the COVID-19 vaccine. For example,
providers with less than 55 percent of members vaccinated received $10 per member
vaccinated, and providers with at least 70 percent of members vaccinated received $100
per member vaccinated. To receive the incentive, providers were required to submit
vaccination data to the immunization information system within 3-days of administration.
Page 24 GAO-24-106526 Medicaid COVID-19 Vaccination Data
to beneficiaries, such as $50 gift cards. 48 Offering beneficiary incentives
was an effective strategy, according to managed care organization
officials in Michigan. In contrast, officials with a managed care
organization in Maryland told us they did not find this strategy effective
because of vaccine hesitancy among members. Findings in research
studies we identified also suggested that incentives can be helpful, but
are not particularly effective among the vaccine hesitant. 49
Targeted Outreach Medicaid programs in California, Maryland, and Michigan also used
patient-level vaccination data to support efforts to target outreach to
Medicaid beneficiaries who had not yet received a vaccination or were
due for an additional vaccination. For example, Medicaid officials in two
states (California and Maryland) told us they provided patient-level data to
managed care organizations regarding their plan members to enable
those organizations to target outreach to and engage in one-on-one
conversations with beneficiaries to encourage vaccination. For instance,
officials from the California Medicaid managed care organization we
interviewed said they used that information to identify providers with the
highest percentage of unvaccinated beneficiaries. The officials said they
then sent these providers toolkits to help combat misinformation that
included posters, post cards for beneficiaries, and a script to use when
talking with patients.
Additionally, officials from the managed care organizations in all three
states said that patient-level data helped them determine which
beneficiaries to contact through text message campaigns or other
targeted communication, like email or mailings, to remind them to get
vaccinated or share information about the benefits of vaccination. For
instance, officials from the Michigan managed care organization said they
sent unvaccinated beneficiaries text messages containing information on
nearby clinics or CDC information about the vaccination, depending on
the beneficiaries’ responses to prompts in the text. These officials also
reported that their use of texting was more successful than phone call
48While the California Medicaid program did not provide direct incentives to beneficiaries,
managed care organizations could opt to provide non-monetary incentives (e.g., gift
cards) that did not exceed $50 in value per member. According to data provided by
California Medicaid officials, the state reimbursed these organizations for a total of $36
million, ranging from $2,400 to $12 million per organization.
49See Neil K.R. Sehgal, “Impact of Vax-a-Million Lottery on COVID-19 Vaccination Rates
in Ohio,” The American Journal of Medicine, vol. 134, no. 11 (2021); and Mireille
Jacobson et al., “Can Financial Incentives and Other Nudges Increase COVID-19
Vaccinations Among the Vaccine Hesitant? A Randomized Trial,” Vaccine, vol. 40, no. 43
(2022).
Page 25 GAO-24-106526 Medicaid COVID-19 Vaccination Data
outreach, and they plan to incorporate texting campaigns into future
efforts. One study we reviewed also identified text messaging and digital
communication as an effective strategy for reaching unvaccinated
individuals during the COVID-19 public health emergency. 50
In addition to incentives and targeted outreach, Medicaid officials in the
four selected states with access to patient-level COVID-19 vaccination
data from immunization information systems (California, Georgia,
Maryland, and Michigan) reported using that data to develop tools to track
vaccination rates. For example, Michigan officials told us they developed
an internal dashboard that tracked COVID-19 vaccination status for
beneficiaries in managed care plans across different demographics, such
as race and ethnicity, age, and geographic area. The dashboard provided
aggregate data on vaccination rates to help managed care organizations
monitor and improve vaccination rates.
Selected States’ Medicaid Medicaid officials in five of our six selected states (California,
Programs Used Medicaid Connecticut, Idaho, Maryland, and Michigan) also described using data
other than, or in addition to, immunization information system data to
Claims and Other Data to
increase vaccination rates among high-risk and vulnerable Medicaid
Increase Vaccination beneficiaries, who are most at risk of adverse outcomes from COVID-19
Rates Among High-Risk complications. According to CMS officials, the agency encouraged state
and Vulnerable Medicaid programs to use all available data to help inform approaches for
vaccinating beneficiaries, and states used a variety of approaches. 51
Populations
Medicaid officials in five of the six selected states (California, Connecticut,
Idaho, Maryland, and Michigan) told us Medicaid claims data helped them
to identify high-risk beneficiaries, including those with existing medical
conditions or comorbidities, who were more likely to face hospitalization
from COVID-19. For instance, Connecticut Medicaid and managed care
organization officials told us they used this approach to focus efforts on
improving vaccination rates among high-risk groups. Michigan Medicaid
officials said claims data helped them identify and target efforts for
homebound individuals.
50See Lynett Ford et al., “Personalized Digital Health Communications to Increase
COVID-19 Vaccination in Underserved Populations: A Double Diamond Approach to
Behavioral Design,” Frontiers in Digital Health, vol. 4 (2022).
51For example, CMS’s COVID-19 Toolkit provided guidance and high-level
recommendations to state Medicaid programs, and recommended state Medicaid
programs collaborate with public health departments to increase COVID-19 immunization
rates and obtain immunization data.
Page 26 GAO-24-106526 Medicaid COVID-19 Vaccination Data
In three of the six selected states (California, Connecticut, and Michigan),
Medicaid or managed care organization officials described using health
indexes, such as CDC’s Social Vulnerability Index or other state-specific
health indexes, to identify vulnerable populations and determine where to
target vaccination efforts. 52 For example, in Connecticut, officials from a
managed care organization told us that social vulnerability index data
helped them target communication about the vaccine to specific zip codes
with high vulnerability.
Effectiveness of Specific While selected states implemented several strategies to increase
COVID-19 Vaccination vaccination rates among Medicaid beneficiaries, state Medicaid officials
said that the nature of the COVID-19 public health emergency caused
Strategies Used by
challenges assessing the effectiveness of any specific strategies they
Selected States is implemented. As a result, the effectiveness of any specific strategy
Unclear; COVID-19 remains unclear. For example, officials stated
Vaccination Efforts
• it was necessary to implement multiple efforts concurrently to increase
Affirmed Importance of
vaccinations, so it is difficult to attribute changes in vaccination rates
Collaboration to any one effort;
• many efforts (e.g., mobile clinics) were focused on increasing
vaccinations in communities at-large, not just among Medicaid
beneficiaries; and
• some states did not have complete data on Medicaid beneficiaries
who received the COVID-19 vaccine. 53
Due to these challenges, several state Medicaid officials and CMS
officials told us they do not plan to assess the relative effectiveness of
52CDC’s social vulnerability index collects data on 16 social factors, including high
poverty, low percentage of vehicle access, or crowded households, to rank the social
vulnerability of geographic areas and to identify communities that might need additional
support during emergencies, including the COVID-19 pandemic. California used the
Healthy Places Index, developed by the Public Health Alliance of Southern California, to
identify vulnerable communities.
53Because the federal government purchased and distributed COVID-19 vaccines free of
charge during the COVID-19 public health emergency, Medicaid claims do not capture the
scope of all COVID-19 vaccines administered to Medicaid beneficiaries. According to
CMS officials, although the agency requires Medicaid programs to collect and report
claims data for instances in which Medicaid provided reimbursement for vaccination
administration, it does not require Medicaid programs to report such data when
vaccinations are administered or paid for by other entities. As such, according to CMS
officials, it is not possible for CMS to estimate vaccination rates during the COVID-19
public health emergency for Medicaid beneficiaries. CMS officials told us that now that
COVID-19 vaccines are paid for by Medicaid, there should be more consistency in the
capture of vaccination data in claims across states, which will in turn be reported to CMS.
Page 27 GAO-24-106526 Medicaid COVID-19 Vaccination Data
state strategies on COVID-19 vaccination rates for Medicaid
beneficiaries. 54
Among the four selected states that had access to patient-level COVID-
19 vaccination data from immunization information systems (California,
Georgia, Maryland, and Michigan), available data show disparities
persisted between vaccination rates for Medicaid beneficiaries and the
statewide population during the COVID-19 public health emergency.
Specifically, our review of state-reported data among these four states—
which vary by time period and age group—generally show between a 16
and 35 percentage point difference between the vaccination rate for the
Medicaid population and the rate for the statewide population.
State officials noted that various factors may have contributed to such
disparities. For example, Michigan officials noted that Medicaid
beneficiaries often are, in general, vaccinated at lower rates for other
types of vaccinations compared to the general population. According to
Medicaid officials in Michigan, this may be due, in part, to barriers noted
earlier, such as transportation challenges and vaccine hesitancy.
According to analysis conducted by the Medicaid and CHIP Payment and
Access Commission, in general, vaccination rates for influenza, tetanus,
and most other vaccines were lower for adult Medicaid beneficiaries than
for adults with private health insurance. 55
Although the effectiveness of specific strategies on improving COVID-19
vaccination rates among Medicaid beneficiaries is unclear, state and
federal officials told us the COVID-19 public health emergency affirmed
the importance of strong, collaborative relationships between state
Medicaid and public health departments to better leverage available data,
as well as ensure access to vaccinations and reduce barriers. 56 According
54California Medicaid officials told us they are in the process of evaluating their incentive
program for managed care organizations, which will include a review of managed care
organizations’ successes and challenges in meeting the program’s goals. Officials said
they anticipate that this evaluation may help to inform ongoing and future vaccination
efforts.
55See Medicaid and CHIP Payment and Access Commission, “Report to Congress on
Medicaid and CHIP” (Washington, D.C.: March 2022), chapter 2.
56The Association of Immunization Managers emphasized the value of collaboration
between Medicaid and immunization programs—including to overcome barriers related to
COVID-19—in its November 2020 checklist identifying ways to improve data exchange
between public health and Medicaid. See Association of Immunization Managers,
“Collaborating with Medicaid to Improve Vaccination Rates: A Checklist for Immunization
Program Managers” (Rockville, Md.: Nov. 21, 2020).
Page 28 GAO-24-106526 Medicaid COVID-19 Vaccination Data
to CDC and CMS officials, strong, collaborative relationships between
programs are important for the ongoing exchange and use of vaccination
data. Similarly, such relationships would be crucial during any future
public health emergency involving an infectious disease.
Medicaid officials in three selected states (Georgia, Idaho, and Michigan)
told us increased collaboration during the public health emergency
fostered more discussions with public health officials, including
discussions about data sharing and data use going forward. For example,
Georgia Medicaid officials told us the COVID-19 public health emergency
demonstrated how both Medicaid and the public health agency could
benefit from accessing one another’s data and noted that both agencies
are interested in exchanging data for other uses, such as addressing
maternal mortality.
Additionally, CDC and CMS officials noted that the COVID-19 public
health emergency amplified the importance of collaboration between state
Medicaid programs and public health departments to ensure Medicaid
beneficiaries obtain recommended vaccinations, and officials from both
agencies told us they continue to emphasize the value of such
relationships in their interactions with state officials. 57 In support of such
relationships, CDC funds a cooperative agreement focused on creating
collaborations between public health departments and Medicaid to better
understand barriers to immunization for Medicaid-enrolled populations
57The Medicaid and CHIP Payment and Access Commission also noted that COVID-19
highlighted existing limitations related to immunization information systems and data
sharing, and identified interoperability, data quality, and timeliness as some of the barriers
contributing to lower vaccination rates among adults enrolled in Medicaid compared to the
general population. They made several recommendations to address barriers, including
that Congress provide additional federal funds to improve immunization information
systems and require CMS, CDC, and other relevant agencies within HHS to release
federal guidance and implement standards to improve immunization information system
data collection and interoperability with state Medicaid data systems as well as electronic
health records. See Medicaid and CHIP Payment and Access Commission, “Report to
Congress on Medicaid and CHIP” (Washington, D.C.: June 2022), chapter 3.
Page 29 GAO-24-106526 Medicaid COVID-19 Vaccination Data
and improve immunization rates. 58 In September 2023, CDC awarded
additional funds under the cooperative agreement, which will run through
September 2026. According to CDC, this effort will also facilitate a
broader learning network consisting of Medicaid and public health officials
to help share promising and best practices for improving vaccination
rates.
We provided a draft of this report to HHS for review and comment. HHS
Agency Comments provided technical comments, which we incorporated as appropriate.
We are sending copies of this report to the Secretary of Health and
Human Services, the appropriate congressional committees, and other
interested parties. In addition, this report will be available at no charge on
the GAO website at http://www.gao.gov.
If you or your staff members have any questions about this report, please
contact me at (202) 512-7114 or lathamc@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. Major contributors to this report are listed
in appendix III.
Catina B. Latham
Director, Health Care
58Under the first iteration of the CDC-funded cooperative agreement, which began in
2017, five states (Colorado, Hawaii, Kentucky, Montana, and New Mexico) participated.
The second iteration began in 2020 and included six states (Louisiana, Michigan, Texas,
Washington, Wisconsin, and Wyoming). Documentation describing outcomes from the
second iteration indicate regular collaboration between Medicaid and immunization
programs was a successful outcome in three states (Michigan, Texas, and Washington)
and resulted in joint guidance and updates to health plans and beneficiaries. Additionally,
four state public health departments (Louisiana, Michigan, Texas, and Washington) noted
they improved their ability to regularly share immunization data with the Medicaid
program, and a fifth state’s public health agency (Wyoming) began the process of setting
up such data sharing.
Page 30 GAO-24-106526 Medicaid COVID-19 Vaccination Data
Appendix I: Medicaid Program Changes to Appendix I: Medicaid Program Changes to
Support COVID-19 Vaccination Activities
Support COVID-19 Vaccination Activities
Congress and the Centers for Medicare & Medicaid Services (CMS)
made temporary changes to the Medicaid program during the public
health emergency to help ensure beneficiaries had access to COVID-19
vaccinations. 1 For example, to incentivize providers to administer the
COVID-19 vaccination to Medicaid beneficiaries, states were permitted to
increase the provider reimbursement for that service. (See table 2.)
These changes were permitted through a period of time after the end of
the public health emergency, depending on the specific flexibility.
Table 2: Examples of Medicaid Program Changes to Respond to the COVID-19 Public Health Emergency
Description Rationale
Federal law required states to provide and administer COVID-19 Eliminated cost as a barrier to vaccination.
vaccines to Medicaid beneficiaries free of cost.
Federal law provided enhanced federal matching rate to cover costs Reduced the costs to states in increasing vaccination rates
associated with COVID-19 vaccines and administration. among Medicaid beneficiaries.
CMS allowed states to align fees paid to Medicaid providers to Incentivized providers who do not generally administer
administer the vaccine with Medicare payments rates.a vaccinations to Medicaid beneficiaries.
Federal law made it possible for states to permit additional categories Increased range of providers that can be reimbursed for
of providers (e.g., pharmacists, pharmacy technicians) to administer administering vaccinations to Medicaid beneficiaries.
the COVID-19 vaccination in states where they did not already have
authority.b
CMS provided coverage and payment at an enhanced federal Helped address vaccine hesitancy by helping beneficiaries and
matching rate for health care providers to provide patients or their families learn about vaccines from trusted health care
caregivers counseling about the COVID-19 vaccination when this providers.
counseling is covered for Medicaid beneficiaries under the age of 21.
CMS allowed states to provide vaccination coverage to Medicaid Increased types of individuals eligible to obtain COVID-19
beneficiaries in limited coverage groups, such as individuals only vaccinations free of charge through Medicaid.
eligible for family planning benefits.c
Source: GAO analysis of Centers for Medicare & Medicaid Services (CMS) COVID-19 guidance. | GAO-24-106526
a
CMS established reimbursement rates under the Medicare program for costs associated with
administering the COVID-19 vaccination at $40 and permitted state Medicaid programs to apply for
approval to adopt the same reimbursement rates to offset higher administration costs, such as to
offset costs for providers in rural areas or transportation costs.
b
See, e.g., Pub. L. No. 109-148, Division C, 119 Stat. 2680, 2818 (2005) and declarations issued
thereunder.
c
Federal law typically limits states to providing limited benefits to these beneficiaries. See Centers for
Medicare & Medicaid Services, Center for Medicaid and CHIP Services, Medicaid, Children’s Health
Insurance Program (CHIP), and Basic Health Program (BHP) Related Provisions in the American
Rescue Plan Act of 2021, Informational Bulletin (Baltimore, Md.: June 2021).
1Medicaid allows significant flexibility for states to design and implement their programs.
For example, states can request waivers of certain federal requirements to target certain
populations or test new or innovative approaches for managing the health care needs of
beneficiaries. In addition to its normal authority to approve these state waiver applications,
CMS has additional authorities to waive Medicaid requirements to help ensure the
availability of care in certain emergency circumstances.
Page 31 GAO-24-106526 Medicaid COVID-19 Vaccination Data
Appendix II: Barriers to COVID-19
Appendix II: Barriers to COVID-19 Vaccination
and Strategies to Address Them
Vaccination and Strategies to Address Them
According to the Centers for Disease Control and Prevention (CDC),
barriers can hinder access to and receipt of vaccinations within certain
communities. To increase COVID-19 vaccination rates, CDC encouraged
state and local jurisdictions to use a variety of strategies to help improve
COVID-19 vaccination rates. 1
According to CDC, barriers to COVID-19 vaccination include the
following:
• Some individuals may face challenges traveling to a provider
administering vaccinations due to lack of transportation or inability to
take time off work. Additionally, people with disabilities, homebound
individuals, or individuals who reside in long-term care facilities may
not be able to travel to get a vaccine. An individual may also lack
internet access or the technical skills required to search online for
vaccination sites or appointments.
• Some individuals lack the information they need to understand the
risks, benefits, and background of vaccine development to make an
informed decision about getting vaccinated.
• Some individuals may have mistrust of certain institutions including
government, medical institutions, and media, which can affect
decisions about vaccination. 2
CDC guidance suggests that states consider implementing the following
strategies to help address barriers:
• Support school- and work-based vaccination clinics to help reach
individuals with limited availability to seek out vaccination.
• Provide community- or neighborhood-based vaccination clinics to help
to reach individuals who are homebound or specific neighborhoods
with low vaccination rates.
• Partner with trusted community members (e.g., faith leaders) or
trusted messengers (e.g., experts or health care providers) to help
share important health information.
1For example, see Centers for Disease Control and Prevention, COVID-19 Vaccination
Field Guide: 12 Strategies for Your Community (August 2021).
2See GAO, COVID-19: Federal Efforts to Provide Vaccines to Racial and Ethnic Groups,
GAO-22-105079 (Washington, D.C.: Feb. 7, 2022).
Page 32 GAO-24-106526 Medicaid COVID-19 Vaccination Data
Appendix II: Barriers to COVID-19 Vaccination
and Strategies to Address Them
• Offer vaccinations during routine patient visits or reminding individuals
of upcoming vaccination appointments through phone calls or text
messaging using appropriate language-based or translation services.
Medicaid and managed care officials in our six selected states (California,
Connecticut, Georgia, Idaho, Maryland, and Michigan) described various
strategies they used to help improve COVID-19 vaccination rates. These
strategies did not involve the use of patient-level COVID-19 vaccination
data from immunization information systems. (See table 3.)
Table 3: Examples of Strategies to Improve COVID-19 Vaccination Rates Used by Medicaid Programs in Six Selected States
State Strategy
California Medicaid officials told us that they sent newsletters to beneficiaries’ households, which included information
about the COVID-19 vaccination.
Officials at one of the state’s managed care organizations described implementing a number of strategies. The
managed care organization
• provided newsletters to members to combat misinformation about the vaccine;
• partnered with over 40 community-based, education, public health, and faith-based organizations to sponsor
over 50 vaccination events in vaccine-hesitant neighborhoods experiencing low vaccination rates, primarily
targeting Black and Latino communities;
• shared information about the vaccine at events and through social media;
• partnered with other health plans, health departments, local sports teams, social media influencers, and
celebrities to encourage vaccination;
• coordinated with a transportation vendor to schedule transportation for COVID-19 testing and vaccination,
and to waive the 2-day appointment scheduling requirement for transport; and
• coupled vaccination clinics with other services such as food pantries or back-to-school giveaways.
Connecticut Medicaid officials told us they
• covered the cost of transportation to vaccination sites, transportation that would ordinarily not be
reimbursable;
• partnered with the state public health department to sponsor vaccination clinics and develop community-
based strategies to conduct outreach to populations disproportionately impacted by COVID-19 (e.g.,
partnered with barber shops, hairdressers, and other places frequented by members of the Black and
Hispanic communities); and
• partnered with the state public health department to notify communities where mobile vans were
administering COVID-19 vaccinations.
Officials at the state’s managed care organizations described implementing a number of strategies:
• Assisted beneficiaries in scheduling COVID-19 vaccination appointments.
• Conducted outreach to beneficiaries through phone calls and text.
• Partnered with the state public health department, as well as social services in the state, to provide
information about the vaccine.
• Conducted general outreach to providers and provided information about the COVID-19 vaccine through
newsletters.
• Provided vaccination information more broadly through social media, webinars, and townhall events.
Page 33 GAO-24-106526 Medicaid COVID-19 Vaccination Data
Appendix II: Barriers to COVID-19 Vaccination
and Strategies to Address Them
State Strategy
Georgia Officials at one of the state’s managed care organizations described that their organization
• broadly shared information about the vaccine with beneficiaries; and
• partnered with community organizations, local sports teams, and local influencers to encourage
vaccinations.
Idaho Medicaid officials told us they
• sent postcards to households with vaccine-eligible members that provided information on the COVID-19
vaccine, and
• shared information about the vaccine with providers through newsletters and other communications.
Maryland Medicaid officials told us they
• collaborated with school-based health centers, federally qualified health centers, local health departments,
as well as providers in target areas to improve vaccination rates;
• partnered with the state’s call center to conduct outreach and encourage vaccination in certain geographic
regions; and
• developed partnerships with the NAACP and Casa de Maryland to address vaccine hesitancy.
Officials at one of the state’s managed care organizations described that they
• conducted outreach to beneficiaries through phone calls and texts;
• shared vaccination information with providers;
• partnered with the state public health department, as well as other managed care organizations in the state,
to provide information about the vaccine at events;
• partnered with a local sports team to encourage vaccinations; and
• partnered with a local organization to conduct community-based outreach to share information with
beneficiaries, including QR codes that members could scan to get vaccination information.
Michigan Medicaid officials told us they
• partnered with the state public health department to sponsor vaccination clinics and develop community-
based strategies; and
• provided vaccination information to beneficiaries to combat misinformation about the vaccine.
Officials at one of the state’s managed care organizations described that their organization
• used a texting campaign to share vaccination information with beneficiaries;
• assisted with scheduling transportation to vaccination appointments;
• partnered with pharmacies to set aside special vaccination appointment times to allow individuals more
flexibility to schedule appointments;
• used a consumer advisory committee to better understand and identify trusted individuals within the
community; and
• developed partnerships with trusted individuals, such as those in churches or community centers, to share
information about the vaccine.
Source: GAO review of information collected from Medicaid programs and managed care officials in selected states. | GAO-24-106526
Page 34 GAO-24-106526 Medicaid COVID-19 Vaccination Data
Appendix III: GAO Contact and Staff
Appendix III: GAO Contact and Staff
Acknowledgments
Acknowledgments
Catina B. Latham, (202) 512-7114 or LathamC@gao.gov
GAO Contact
In addition to the contact named above, Shannon Legeer (Assistant
Staff Director), Kimberly Lloyd Perrault (Analyst-in-Charge), Benjamin T.
Acknowledgments Feldman, Joy Grossman, Emma Hultgren, Drew Long, Monica Perez-
Nelson, Andrea E. Richardson, and Ethiene Salgado-Rodriguez made
key contributions to this report.
Page 35 GAO-24-106526 Medicaid COVID-19 Vaccination Data
Related GAO Products
Related GAO Products
Electronic Health Information Exchange: Use Has Increased, but Is Lower
for Small and Rural Providers. GAO-23-105540. Washington, D.C.: April
21, 2023.
COVID-19: HHS Funds Allocated to Support Disproportionately Affected
Communities. GAO-23-105500. Washington, D.C.: January 24, 2023.
Adult Routine Vaccinations: Adult Rates Vary by Vaccine Type and Other
Factors. GAO-22-105334. Washington, D.C.: September 15, 2022.
COVID-19: Pandemic Lessons Highlight Need for Public Health
Situational Awareness Network. GAO-22-104600. Washington, D.C.:
June 23, 2022.
COVID-19: Current and Future Federal Preparedness Requires Fixes to
Improve Health Data and Address Improper Payments. GAO-22-105397.
Washington, D.C.: April 27, 2022.
COVID-19: Federal Efforts to Provide Vaccines to Racial and Ethnic
Groups. GAO-22-105079. Washington, D.C.: February 7, 2022.
COVID-19: Sustained Federal Action Is Crucial as Pandemic Enters Its
Second Year, GAO-21-387. Washington, D.C.: March 31, 2021.
Medicaid Information Technology: Effective CMS Oversight and States’
Sharing of Claims Processing and Information Retrieval Systems Can
Reduce Costs. GAO-20-179. Washington, D.C.: September 9, 2020.
Health Information Technology: Approaches and Challenges to
Electronically Matching Patients’ Records across Providers. GAO-19-197.
Washington, D.C.: January15, 2019.
Electronic Health Records: Nonfederal Efforts to Help Achieve Health
Information Interoperability. GAO-15-817. Washington, D.C.: September
16, 2015.
Electronic Health Records: HHS Strategy to Address Information
Exchange Challenges Lacks Specific Prioritized Actions and Milestones.
GAO-14-242. Washington, D.C.: March 24, 2014.
Page 36 GAO-24-106526 Medicaid COVID-19 Vaccination Data
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