By Leila Sullivan
With infectious diseases such as measles on the rise, many Americans are wondering what they can do to protect themselves and loved ones against illness. Some adults may not have been vaccinated as children but want to protect themselves now. Others past a certain age may be uncertain if vaccines received in childhood still provide adequate immunity. But, as with so many questions about healthcare, many will worry about the costs associated with seeking the care they need. This post walks through what insurers are and are not required to cover under current federal law.
Infectious Disease Cases Rising in the U.S.
As of April 18th, there have been almost 600 cases of measles reported as part of an outbreak in Texas, with cases more recently appearing in Louisiana, Missouri, and Virginia. The Texas Department of State Health Services has shared that almost all the cases have been in individuals either lacking the MMR vaccine or with an unknown MMR vaccine status. So far, two children have died, the first reported measles deaths in the United States since 2015, but officials warn that number could rise, and are encouraging people to get the MMR vaccine.
Another infectious illness rising over the past few years is whooping cough, otherwise known as pertussis, which can be protected against via the Tetanus, Diphtheria, and acellular Pertussis (TdaP) vaccine and boosters. Louisiana alone has reported 110 cases of pertussis so far this year, with two infant deaths in the last six months. In 2024 there were more than 35,000 cases of pertussis reported nationally – the highest in over a decade – and experts say declining vaccination rates are the main culprit.
The incidence of these and other infectious diseases is likely to rise in the U.S., fueled not only by declining vaccination rates and increased vaccine hesitancy, but also by the dismantling of USAID and other U.S.-supported efforts to prevent, detect and contain illness abroad.
At Risk: The Affordable Care Act Guarantee of Free Recommended Vaccines
The Affordable Care Act (ACA) requires non-grandfathered individual and employer-based health insurance plans to cover a wide array of preventive services without cost-sharing, including recommended vaccines. Under the law, the federal Advisory Committee on Immunization Practices (ACIP) within the Centers for Disease Control and Prevention (CDC) recommends the vaccines that plans and insurers are required to cover.
Coverage for preventive services is one of the most popular provisions of the ACA. However, the Supreme Court heard oral arguments April 21st in Kennedy v. Braidwood Management Inc., a case with the potential to substantially weaken the guarantee of no-cost preventive services that millions of Americans have come to depend upon. Regardless of that case’s outcome, Robert Kennedy Jr, now the Secretary of Health & Human Services (HHS) and a longtime skeptic of the science supporting vaccines, has asserted his authority to ratify ACIP recommendations, remove ACIP members at will, and appoint new ACIP members that may share his views. If the Secretary decides to rescind ACIP recommendations of current vaccines, or refuse to ratify recommendations for future vaccines, health plans and insurers would have no obligation under the ACA to maintain coverage and waive patient cost-sharing.
Vaccines, Boosters, and Titer Tests: What Will Health Plans Cover?
Vaccines teach the body how to fight off specific diseases, and a booster, otherwise referred to as an additional dose, builds upon that by strengthening already existing immunity. Most Americans receive a majority of their vaccines as children, but when people are unsure of their vaccine status or are old enough to be concerned about the level of immunity provided by a vaccine administered in childhood, their doctor may order titer tests. Titer tests, or antibody titers, are tests done to measure the amount of antibodies in a person’s blood to determine their level of immunity to a particular disease.
Titer tests
ACIP does not generally recommend routine titer tests, opting only to recommend them in cases of high risk of exposure such as rabies titers for vets and hepatitis B titers for certain healthcare workers. If a provider recommends a titer test that is not recommended by ACIP, health plans are not required to cover the cost. Individuals should contact their insurers to ask about coverage for their particular circumstance.
Vaccines
ACIP recommends that children from birth to age 18 receive vaccines for serious diseases such as varicella (chicken pox,) measles, mumps, and rubella (MMR,) rotavirus, and hepatitis A, among others. For adults who lack or have incomplete vaccine records, ACIP recommends providers administer these same vaccines, which in turn triggers health plans to cover, and waive cost-sharing for, vaccination in these circumstances.
Vaccine Boosters
As people age, vaccine effectiveness wanes, while they also become more susceptible to illness exacerbated by underlying conditions. ACIP thus recommends additional doses or boosters for specific vaccines and different groups. Currently, ACIP recommends an array of additional doses depending on many factors including age, pregnancy status, country of birth, or coexisting conditions. People should speak with their healthcare providers to determine what vaccines and boosters are right for them; if they are on the ACIP recommended list, most commercial insurance plans must cover them without enrollee cost-sharing. For vaccines not on the ACIP recommended list, plans may cover them with or without cost-sharing at their own discretion.
Coverage for the Un- and Underinsured
For adults without health insurance, local public health departments, federally funded health centers, or charitable organizations may provide free or low-cost vaccine services. However, recent cuts in federal funding have jeopardized many local vaccine programs, such as for flu and COVID-19.
Many people are also enrolled in coverage arrangements that do not have to comply with the ACA, and thus may not cover vaccines, or may require cost sharing. These include products such as short-term health plans, fixed indemnity insurance, and arrangements such as health care sharing ministries (HCSMs). Unless mandated by state law, these plans are not required to cover preventive services. Many may impose cost-sharing or do not cover vaccines at all.
Takeaways
Infectious disease is on the rise, local public health programs providing preventive services face a loss of federal funding, and the ACA’s guarantee of free preventive care is at risk in the Supreme Court and at HHS. For those who want to protect themselves and stay healthy, now is a good time to talk to your doctor about the potential needs for vaccines or booster shots. However, it’s probably wise to call your health plan and check your coverage at the same time.
