Vaccine Coverage Requirements Vary by Market

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Avalere has released a new white paper explaining the current insurance coverage requirements for vaccines and the laws that govern those requirements for the Medicare (Parts B and D), Medicaid, and commercial (group and individual) markets.
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The requirements for insurance coverage of vaccines vary across the commercial, Medicaid, and Medicare markets, including whether plans must cover vaccines and whether patient cost sharing is permitted. These requirements have changed significantly over time, with the most recent standards implemented through the Affordable Care Act (ACA).

Historically, issuers in the commercial insurance market could choose whether or not to cover vaccines in their plans. A 2001 National Survey of Employer-Sponsored Health Plans found that health maintenance organizations (HMOs) frequently included vaccines as a basic benefit, covering 66% of adult vaccines, while preferred provider organizations (PPOs) did not cover vaccines as commonly, with 57% of adult vaccines covered.1 Issuers that chose to cover vaccines could control utilization through formulary placement and cost sharing. The Centers for Disease Control and Prevention’s (CDC) 2002 National Immunization Survey found that 79% of privately insured children faced out-of-pocket costs for their most recent vaccination visit.2

Recognizing the public health value of vaccines as a preventive service and the negative relationship between cost sharing and vaccine uptake,3 Congress and the Centers for Medicare and Medicaid Services (CMS) eventually implemented vaccine coverage and cost-sharing requirements in commercial, Medicaid, and Medicare plans. These standards vary significantly by market, however.

1. Institute of Medicine, (US) Committee on the Evaluation of Vaccine Purchase Financing in the United States, Financing Vaccines in the 21st Century (Washington, DC: National Academies Press, 2003);, October 5, 2017).

2 Institute of Medicine, Financing Vaccines.

3. Charles Stoecker, Alexandra M. Stewart, and Megan C. Lindley, “The Cost of Cost-Sharing: The Impact of Medicaid Benefit Design on Influenza Vaccination Uptake.” Vaccines 5.1 (March 6, 2017): 8;

Webinar | A Closer Look at Patient Support On June 6 at 2 PM ET, Avalere experts will explore how potential implications of the Inflation Reduction Act (IRA)’s out-of-pocket cap, in addition to other key regulatory and policy activities shaping benefit design and patient cost-share (e.g., EHB), could impact patient commercial and foundation assistance. Learn More
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