For now, most Americans can still breathe a sigh of relief: Covid-19 vaccines remain free of charge for the majority. But here's where it gets tricky. While the US Centers for Disease Control and Prevention (CDC) has shifted its stance on Covid-19 immunization, requiring individuals to consult with healthcare providers for a shared clinical decision, the financial implications aren't as clear-cut.
The CDC's advisory committee voted to move away from a blanket recommendation for Covid-19 vaccines, introducing a layer of complexity. This change has sparked concerns about potential out-of-pocket costs for some individuals. The Affordable Care Act mandates that private insurers cover vaccines recommended by the CDC’s Advisory Committee on Immunization Practices (ACIP) at no cost. Similarly, Medicaid’s no-cost coverage is tied to these recommendations.
And this is the part most people miss: Medicare, by law, must cover the Covid-19 vaccine without any cost-sharing, so it remains unaffected. A spokesperson for the US Department of Health and Human Services assured that immunization coverage would continue through various payment mechanisms, including entitlement programs like Medicaid and Medicare, as well as federal insurance plans.
However, experts caution that the situation isn’t entirely straightforward. Amy Killelea, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms, points out that insurers may not unanimously agree on covering vaccines under shared decision-making recommendations at no cost. This ambiguity arises despite the CDC’s clarification that such recommendations should fall under Obamacare’s mandate.
Many private insurance plans are regulated by the Departments of Health and Human Services, Labor, and Treasury, which have yet to issue guidance on shared decision-making. Meanwhile, at least 13 states have taken steps to ensure insurers continue providing free Covid-19 vaccines, according to KFF, a nonpartisan health policy research group.
The nation’s largest health insurer trade association, AHIP, has stated that its members—covering over 200 million Americans—will maintain no-cost coverage for all immunizations recommended by ACIP as of September 1, including the updated Covid-19 vaccine, through the end of 2026. UnitedHealthcare, the nation’s largest insurer, has also committed to fully covering ACIP-recommended Covid-19 vaccines in its standard commercial plans, though individuals with job-based policies should verify with their employers.
Blue Cross Blue Shield insurers will similarly cover all committee-recommended vaccines at no cost to patients through the end of next year, operating within federal and state laws.
But here’s the controversial part: Some insurers might argue they’re not obligated to cover the entire $140 cost of the Covid-19 vaccine if it falls under shared decision-making. Killelea notes, “There’s nothing that requires insurers to cover vaccines not recommended by ACIP at no cost. The ambiguity lies in whether all insurers will view a shared decision-making recommendation as a full ACIP recommendation.”
Medicaid enrollees, however, will continue to receive the vaccine at no cost, per earlier guidance from the Centers for Medicare and Medicaid Services.
Shifting focus, the CDC advisory committee also voted to no longer recommend the combined measles, mumps, rubella, and varicella (MMRV) vaccine before age 4. This means private insurers won’t be required to cover it at no cost, potentially leaving parents to pay out of pocket if they opt for this vaccine. Jen Kates, senior vice president at KFF, warns that vaccine manufacturers may even discontinue production of the combined vaccine.
Additionally, the MMRV vaccine will no longer be automatically covered by Medicaid or the Children’s Health Insurance Program, though states have the option to do so. The CDC committee also voted against including the MMRV vaccine in the Vaccines for Children program, which serves low-income children.
Individual vaccines for measles, mumps, rubella, and varicella will remain recommended and covered at no cost.
Now, here’s a thought-provoking question for you: As shared decision-making becomes more prevalent in healthcare, should insurers be mandated to cover vaccines under this model at no cost, or should there be room for interpretation? Let us know your thoughts in the comments below!
