Obamacare: Providing greater access to immunizations

Emmet Pierce

Since the implementation of the Patient Protection and Affordable Care Act (also known as Obamacare) began in 2010, health insurance companies have broadened their coverage for free patient immunizations.

The Affordable Care Act (ACA) requires new health insurance plans to cover preventive care free of charge, including vaccines that are recommended by the Advisory Committee on Immunization Practices (ACIP).

According to the U.S. Department of Health and Human Services, insurers now must administer free adult immunizations to policyholders for the following diseases and conditions:

• Hepatitis A and B.
• Herpes zoster.
• Quadrivalent human papillomavirus for women.
• Influenza.
• Measles.
• Mumps.
• Rubella.
• Meningococcal.
• Pneumococcal.
• Tetanus.
• Diphtheria.
• Pertussis (whooping cough).
• Varicella.

Children must be immunized by insurers without charge for multiple diseases including diphtheria, tetanus, pertussis, haemophilus influenzae type B, hepatitis A, hepatitis B, polio, influenza, measles, mumps, and rubella.

How much will immunizations cost under Obamacare?

These immunizations for adults and children are free (if they have health insurance) and insurers have to cover them without cost sharing, says Sarah Gravelin, a senior client associate for Health Navigation LLC, a health care advocacy and consulting firm based Connecticut. Cost sharing is where insurance companies use co-pays and deductibles to shift their costs to patients.

However, not all immunizations are now covered under health care reform law.

Dr. Julie Kessel, senior medical director for coverage policy at health insurer CIGNA, notes that some immunizations are not considered medically necessary for most people.

When medical conditions are not on the ACIP immunization list, insurance companies may require the patients who receive them to pay a fee.

For example, you cannot receive a free vaccine for rabies , if you haven’t been exposed to the disease by coming into contact with an infected animal, she says. Your insurance company also may decline to pay for vaccines to protect you from the diseases you may encounter by traveling outside the U.S.

“If you are getting a vaccine specifically for the purposes of international travel, that may be excluded,” Kessel says.

Shana Alex Lavarreda, director of health insurance studies and research scientists for the UCLA Center for Health Policy Research, notes that the ACA’s policy against charging insured patients ACIP-recommended immunizations won’t apply if the patients are part of grandfathered health-care plans.

A grandfathered health insurance plan is one that existed before March 24, 2010. A grandfathered plan doesn’t have to meet all of the requirements of the ACA. For example, grandfathered plans are not required to cover preventive care for free. They may not allow patients to appeal coverage decisions. Also, they aren’t required to give patients access to emergency care. Under a grandfathered plan, you may not be able to choose your own doctor.

But a grandfathered plan may not retain that status for long. When an insurer or employer makes significant changes to benefits or changes the amount that the insured must pay through premiums, co-pays or deductibles, the plan no longer can be grandfathered.

Immunizations through health insurance

Lavarreda says providing free immunizations is becoming the norm among insurance companies since Obamacare was passed because of a decline in the number of grandfathered plans around the country. She notes that in California only about 15 percent of health care insurance plans are grandfathered.

She notes that Medicare, a federal system of health insurance that primarily serves people age 65 and older, has adopted ACA standards for seniors, since the passage of the health care reform law.

“Medicare is covering immunization for the elderly for free,” she says.

Insurance company immunization practices have become more standardized since the passage of the ACA, says Dr. Esther Nash, vice president and medical director of comprehensive care at Health Advocate Inc., a company that helps consumers navigate through the health- care market.

“Prior to this, there was more variation in the commercial market,” she says.

Gravelin says insurance plans still may charge for immunizations, if patients seek care outside of their assigned network of caregivers.

Immunizations for the uninsured

If you don’t have health insurance, there still are ways to receive immunizations at little or no cost, Nash says. Low-income patients often can get free immunizations through government programs.

Many county health departments offer free vaccines to low-income residents, she explains. Each county health department in the country determines which vaccines it will offer for free to low-income residents, she says. “It’s worth checking out for people who don’t have access (to health care) through insurance.”

Some urgent care facilities offer vaccines at reasonable rates. Nash notes that many employers offer free influenza vaccines to their workers each year to reduce absenteeism due to illness.

Children and pregnant women may be able to get free immunizations from Medicaid, a program for low-income people that is financed by states and the federal government. Eligibility will depend on regulations in each state, Kessel says.

The federal Vaccines for Children program provides immunizations at no cost for children who are Medicaid-eligible, are of Native American ancestry or are lacking health insurance.