State Medicaid Coverage of Human Papillomavirus Vaccination in Adults and Implications for Dermatologists

Abstract

This cross-sectional study examines state Medicaid coverage of human papillomavirus vaccination in adults aged 27 to 45 years and discusses the implications of the results for dermatologists.

The human papillomavirus (HPV) vaccine is approved by the US Food and Drug Administration for all individuals aged 9 to 45 years for the prevention of genital, cervical, anal, and oropharyngeal cancers, as well as genital warts. The Centers for Disease Control and Prevention Advisory Committee on Immunization Practices currently recommends routine vaccination in those aged 9 to 26 years because most benefits are seen before exposure to the virus. However, shared clinical decision-making is recommended in individuals aged 27 to 45 years because benefits may still exist for adults at high risk for new HPV infection.¹ Although dermatologists should routinely recommend HPV vaccination for patients aged 9 to 26 years, certain dermatology patients aged 27 to 45 years, such as those with hidradenitis suppurativa,² atopic dermatitis,³ and systemic lupus erythematosus,⁴ may be at increased risk for persistent and high-risk HPV infection (ie, associated with an increased risk of cancer) and may benefit from vaccination. Despite benefits for such patients, lack of a firm recommendations makes insurance coverage for this age group uncertain.² The objective of this study was to explore state Medicaid coverage policies on the HPV vaccine among adults aged 27 to 45 years to assess the feasibility of dermatologists recommending vaccination to adults at risk.

Methods

In accord with the Common Rule, institutional review board approval was not required for this cross-sectional study because it did not meet criteria for human participants research. This study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. Given the large number and variability of private health insurance formularies, as well as their lack of transparency, we used US Medicaid policies for all 50 states as a proxy for coverage of the insured population in the US. Data were collected from September 14 through December 8, 2021.

Information concerning coverage, age restrictions, and prior authorization requirements was recorded from state Medicaid formularies and policies via websites and email or telephone inquiries. Figure 1 shows the 3-step process used to determine coverage in the 50 states.

Figure 1. Process Used to Determine States’ Human Papillomavirus Vaccination Coverage.

Each subsequent step was taken to identify programs not found in the previous step. If no program was identified in the search for state Medicaid formularies (step 1) or by contacting the state health department (step 2), the largest Medicaid managed care organization (MCO) for the state was identified using 2020 Kaiser Family Foundation Medicaid MCO enrollment list to serve as a proxy for the entire state (step 3); MCOs are privately contracted by most states to administer Medicaid policies and must therefore abide by certain guidelines set by the state Medicaid program.

Results

Overall, 33 states had formal statewide policies for adult HPV vaccination coverage available online or by contacting the state Medicaid office. Four states had formal adult vaccination programs that covered vaccination, and 11 states provided coverage through Medicaid managed care organizations. Information was unavailable for 2 states. In 43 states (86%), HPV vaccination was covered through age 45 years without the need for prior authorization (Figure 2). Prior authorization was required by 4 states (Ohio, Maine, Nebraska, and New York) for adults over the age of 26 years. Mississippi did not provide coverage to adults older than 26 years.

Figure 2. State Medicaid Coverage of Human Papillomavirus Vaccination, by Age.

Discussion

This cross-sectional study found that most state Medicaid plans cover HPV vaccination for adults aged 27 to 45 years. Such widespread coverage should assist dermatologists as they recommend vaccination to adults at high risk and facilitate the incorporation of HPV vaccination into disease-specific management guidelines. In addition to the increased prevalence and persistence of high-risk HPV infection seen in adults with certain dermatologic condition,^2,3,4,5 patients who are immunosuppressed (eg, those taking tumor necrosis factor inhibitors) have been found to be at increased risk for persistent HPV infection and HPV-related cancers.⁶

To our knowledge, this study provides the most current information regarding HPV vaccination coverage, but state Medicaid policies may change over time. A study limitation is our use of Medicaid coverage only, and patients with other types of insurance or who are uninsured may face additional barriers, such as cost; the current retail price for the 3-shot series is $250 to $300 per shot. Further research is needed to better identify dermatology patients at risk for new HPV infection and ways to improve vaccination rates in these vulnerable individuals.