Most Americans are still guaranteed to get Covid-19 vaccines at no cost — for now

By Tami Luhby, CNN

(CNN) — Most Americans with health insurance should not have to pay out of pocket for Covid-19 vaccines, even after the US Centers for Disease Control and Prevention added an extra hurdle to getting the shot. But some people could face new costs.

The CDC adopted its vaccine advisers’ vote to shift away from a broad recommendation for Covid-19 immunization; people who want one must now consult with a health care provider, a process known as shared clinical decision-making. However, a prescription is not necessarily needed.

But the change raised concerns that insurers would no longer be required to cover the full cost of the immunization. The Affordable Care Act mandates that most private insurers cover vaccines recommended by the CDC’s Advisory Committee on Immunization Practices, or ACIP, at no cost. Meanwhile, Medicaid’s no-cost coverage of vaccines is also tied to the committee’s recommendations.

(Medicare is required by law to cover the Covid-19 vaccine with no cost-sharing, so it is not affected by the committee’s recommendation.)

The CDC committee’s vote “provides for immunization coverage through all payment mechanisms including entitlement programs such as Children’s Health Insurance Program, Medicaid, and Medicare, as well as insurance plans through the federal Health Insurance Marketplace,” a US Department of Health and Human Services spokesperson said in a statement last month.

However, it may not be that cut-and-dry, experts said.

Insurers may not unanimously agree that they have to cover vaccines with shared decision-making recommendations at no cost, although the CDC has attempted to clarify that such recommendations should fall under Obamacare’s mandate, said Amy Killelea, an assistant research professor at Georgetown University’s Center on Health Insurance Reforms. That injects “ambiguity” into the extent of the coverage.

Many private insurance plans are regulated by a trio of departments: Health and Human Services, Labor and Treasury, which have not issued guidance on shared decision-making. Other private plans are regulated by states, at least 13 of which have taken steps to require the insurers they regulate to continue to provide Covid-19 vaccines for free to patients, according to KFF, a nonpartisan health policy research group.

Insurers promise free shots through 2026

The nation’s largest trade association for health insurers said its members – which cover more than 200 million Americans – indicated that any recommendations stemming from the committee’s meeting would not have an impact on policyholders’ coverage through the end of 2026.

AHIP, formerly America’s Health Insurance Plans, said in a statement before the ACIP meeting in September that its members would continue to cover all immunizations that the committee had recommended as of September 1 at no cost to patients. This includes the updated Covid-19 vaccine.

“Health plans are committed to maintaining and ensuring affordable access to vaccines,” said the association, which told CNN that shared decision-making recommendations must be covered without cost-sharing. “Health plan coverage decisions for immunizations are grounded in each plan’s ongoing, rigorous review of scientific and clinical evidence, and continual evaluation of multiple sources of data.”

Similarly, UnitedHealthcare said it will fully cover Covid-19 vaccines recommended by ACIP as of January 1 in its standard commercial plans, although it noted that people who have certain job-based policies should check with their employers. UnitedHealthcare, which is not an AHIP member, is the nation’s largest insurer.

“UnitedHealthcare is committed to enabling access to safe, effective and affordable care, including coverage for vaccinations,” the company said in a statement after last month’s ACIP vote. “Vaccines are an important and effective way to protect the health of individuals, families and communities, and members should talk with their health care providers to determine if a vaccine is clinically appropriate.”

The insurer noted that its “coverage will remain guided by federal and state mandates as well as the available clinical evidence, including the recommendations of professional societies such as the American College of Obstetricians and Gynecologists (ACOG), American Academy of Pediatrics (AAP), and American Academy of Family Physicians (AAFP).”

And Blue Cross Blue Shield insurers will cover all vaccines recommended by the committee as of January 1 with no cost to patients through the end of next year, while operating within federal and state laws, according to the Blue Cross Blue Shield Association.

But some insurers could now argue that they aren’t mandated to pick up the entire tab for the Covid-19 vaccine, which costs about $140.

“There’s nothing that requires insurers to cover vaccines not recommended by ACIP at no cost,” Killelea said. “Where it could be ambiguous is whether all insurers will view a shared decision-making recommendation as a full recommendation from ACIP.”

Medicaid enrollees will continue to receive the vaccine at no cost, per earlier guidance from the Centers for Medicare and Medicaid Services, Killelea said.

Harder to get combo MMRV vaccine

Separately, the CDC advisory committee also voted that the combined measles, mumps, rubella and varicella (MMRV) vaccine would no longer be recommended before age 4.

That means private insurers will not be required to cover it at no cost, so if parents want their children to have the combined vaccine, they could have to pay for it – if they could get it at all, said Jen Kates, senior vice president at KFF. Vaccine makers may not continue to manufacture it, she said.

Also, the combined vaccine will no longer be automatically covered by Medicaid and the Children’s Health Insurance Program, though states could opt to do so.

The CDC committee voted not to have the MMRV immunization covered by the Vaccines for Children program, which provides access for low-income children.

The separate vaccines against measles, mumps and rubella and against varicella, the virus that causes chickenpox, will continue to be recommended and will be covered at no cost.

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