Immunizations do more than keep people healthy. They also keep people alive. That isn't the only reason insurance usually covers them, but it is a big one. Here's all you need to know about health plans, shots, and vaccines.
If you have health insurance, you can bet it covers at least a few immunizations or vaccines.
That's true if you get coverage from an employer, an insurance company, the federal or state "marketplace," Medicare, or Medicaid.
Not all health plans cover these shots in the same ways or to the same extent, however. Some cover pretty much any vaccination you might need. Others only cover a handful.
Also, with some health plans, you don't have to pay a dime to get immunized. With others, you're responsible for copayments or co-insurance costs.
Before we get to how health insurance tends to cover (or not cover) vaccines, though, at least some of you probably are wondering why they're so important. Some of you also may be wondering why health plans tend to cover them.
Actually, one sentence basically tackles both situations. Vaccines like flu shots are important, and health plans often cover them, because they keep people healthy and they keep people from dying.
There's a lot more to it than that, of course.
"Medical professionals encourage vaccinations because vaccinations help prepare our immune systems to fight infections before we get them," said Chirag Shah MD, co-founder of Accesa Labs. "Generally, many insurance providers will cover preventative services like vaccines and routine physicals as a way to reduce the probability of having to pay for more expensive care in the future."
For example, consider the following statistics (from the Center for Medicare & Medicaid Services, or CMS):
Also, according to the Centers for Disease Control and Prevention (CDC), 1.25 million people currently are infected with Hepatitis B. This virus attacks the liver and can cause liver cancer, liver failure, and even death.
Given those eye-opening stats, it shouldn't be all that surprising to hear healthfinder.gov (among other sources) recommends that all Americans get:
If you're 60 or older, you should get a few other vaccines, too. A couple of examples: shots that protect against pneumonia and shingles.
Some younger Americans need other immunizations as well. You'll want to talk with a doctor to see if this is the case for you. In general, though, people who need additional shots:
Is it clear to you now why health insurance usually covers flu shots and other kinds of vaccinations?
If not, consider the Kaiser Family Foundation's comment on these and other forms of preventive services:
"Research has shown [they] can save lives and improve health by identifying illnesses earlier, managing them more effectively, and treating them before they develop into more complicated, debilitating conditions."
That same KFF report points out that some of these services "are also cost-effective." In other words, they help insurance companies save money.
There's nothing wrong with that, of course. Insurance companies are businesses, not charities. To survive, they need to turn a profit.
Well, picking up some or all of the costs of a yearly flu vaccine or a once-every-10-years Td shot helps them do that by preventing illness and disease that would cost them a lot more in the long run.
For more information on the many kinds of preventive care health plans usually cover, read our article, "Health Insurance and Preventive Care."
Actually, saving money and saving lives aren't the only reasons most health plans cover flu shots and other vaccines.
Another reason is the Affordable Care Act which many know as Obamacare.
Thanks to that law's passage in 2010, most private insurance plans in the U.S. must cover a slew of immunizations for both children and adults. And they have to do so without any patient cost-sharing. (The deductibles, copayments, and co-insurance fees usually tied to medical care and services are examples of cost-sharing.)
Some of the immunizations or shots private health plans have to cover because of the ACA:
The only exceptions to the above are “grandfathered” health plans. These plans existed before March 23, 2010, which is when Obamacare became law. To maintain their grandfathered status, the insurers that back these plans can't make significant changes to their coverage.
It probably could go without saying that plans sold on the health insurance marketplace (or "exchange") set up by the ACA cover all of the vaccines listed above.
Actually, the same is true of off-marketplace plans. These are plans you buy away from the marketplace, directly from insurance companies.
How about health insurance you get through an employer? Most of them should cover some or all of the shots and vaccines mentioned here as well. The ACA or Obamacare don't require all of them to do so, however.
For instance, especially large companies don't have to meet the ACA's requirements. Most do anyway, though, so expect coverage you get through a large employer to pay for any vaccines or immunizations you might need.
On a related note, any health plans that fall under the ACA's guidelines also must cover Hepatitis B screenings. That said, they don't have to cover them for everyone.
The ACA only requires plans to cover Hepatitis B screenings for high-risk individuals. That includes people from certain countries and certain U.S.-born people not vaccinated as infants.
Medicare Part B, sometimes called "medical insurance," covers a number of preventive services and treatments. Shots and vaccines like the ones discussed so far are among them.
Specifically, Medicare Part B pays for flu, pneumococcal, and Hepatitis B shots.
Before you head to your doctor to get one, though, consider the following:
You also may have to pay all or some of the cost of these shots if your physician or provider suggests you have them done more frequently than Medicare recommends or covers.
To avoid being surprised by an unexpected bill, talk with your doctor or insurer before you agree to or schedule anything. In particular, ask them if Medicare will pay for the shots or vaccines you need.
To learn more about Original Medicare (Medicare Parts A and B) and what it does and doesn't cover, read our article, "Is Medicare Enough? What’s Covered and What's Not Covered?" Check out our "Ultimate Guide to Medicare: Everything You Need to Know," too.
If you need other vaccines and want Medicare to pay for them, look at your Part D coverage. Some Medicare Part D plans cover the shingles vaccine or the Tdap vaccine (which protects against tetanus, diphtheria, and whooping cough), for instance.
For more information, see our article, "Medicare Part D: Prescription drug benefits to people over the age of 65."
Medicaid covers all recommended vaccines for children and some vaccines for adults.
It's difficult to say which vaccines Medicaid covers for adults because every state handles Medicaid differently. That said, most state Medicaid agencies help pay for flu, Hepatitis B, and pneumococcal shots in certain circumstances.
Unlike Medicare, Medicaid doesn't always cover vaccines in full. Depending on where you live and where you get your shot, you may be responsible for a copayment or similar fee.
To find out if Medicaid covers any of the shots of vaccines you need, contact your local agency.
Also, if your state Medicaid agency doesn't currently cover the shots you need, don't give up. The Center for Medicare & Medicaid Services is working with other U.S. Department of Health and Human Services officials to improve vaccination rates in adults.
As for children, Medicaid mainly covers their shots and vaccines through the Children's Health Insurance Program (CHIP). For more information on the specific immunizations CHIP covers, contact your local agency.
There's another way to get kids free or low-cost vaccines if your local Medicaid or CHIP program don't cover them, by the way. The Vaccines for Children (VFC) program provides vaccines to children whose parents or guardians can't afford them.
To qualify, the child has to be younger than 19 years of age. He or she also needs to be one of the following:
In this case, underinsured means your child has health insurance, but it doesn't cover the shots or vaccines he or she needs.
Technically, these shots should be free. That said, doctors can charge a set fee for administering them, so keep that in mind before you seek one. Doctors also can charge a fee for the office visit. And they can charge you for any additional services performed along with the shot (such as an eye exam or blood test).
Do you have a child who needs health insurance coverage? Check out our article, "Health Insurance and Children." You might want to read this one, too: "Everything You Need to Know About Child-Only Health Insurance."
Although most health plans should cover most shots or vaccines you might need, there are times where you may have to pay some of the cost. A few examples, according to kff.org:
A: The best way to prevent the flu is to get vaccinated every year. (Usually during the fall.) Preventing the flu is important because, as cms.gov points out, the flu puts over 200,000 Americans in the hospital each year. Also, an average of 36,000 Americans die every year due to the flu and related complications.
You especially need a flu shot if you have a high risk of developing serious complications should you get sick. This includes:
A: You probably only need to get this shot if you're 65 or older. If that describes you, though, don't ignore this vaccine. Get it even if your health plan won't pay for it. More than 5,000 Americans die from invasive pneumococcal disease every year, and over half of those people are 65 or older.
A: Again, you probably only need to worry about this shot if you're at a high risk for Hepatitis B. That usually means having renal disease or hemophilia. If your doctor recommends this vaccine, though, get it. Hepatitis B can cause lifelong infection, cirrhosis of the liver, liver cancer, liver failure, and even death.
A: Yes, most health plans cover flu shots. Not sure if yours does? Contact your insurance company. Or contact Medicare or your local Medicaid agency (if either of those programs provides your health coverage).
A: Yes, most health plans cover most of the vaccines a person might need. If looking over your policy doesn't make it clear which vaccines or shots it covers, contact your insurer. Or contact Medicare or your local Medicaid agency.
A: Yes, Medicare should cover flu, pneumococcal, and Hepatitis B shots. It doesn't always cover those shots, though, or it doesn't always cover them in full. Talk with your physician and make sure you know if you'll be billed for any part of the procedure before you agree to anything.
A: Yes, Medicaid often covers flu shots as well as some other common vaccines. Talk with someone at your local Medicaid agency if you have any questions about the shots and vaccines you need.
A: Yes, CHIP, aka the Children's Health Insurance Program, covers flu shots for children in need. It also pays for other common vaccinations and immunizations.
Another option for children whose parents or guardians can't afford flu shots or other vaccines: the Vaccines for Children program.
A: In many cases, no, it won't. Most health plans don't cover vaccines needed for traveling outside the U.S. This is true even though these vaccines may be "medically necessary." And insurance usually covers medically necessary care.
Health insurance doesn't cover as much as you might think while you travel, by the way. Learn more about this in our article, "Does Health Insurance Cover Your Medical Care When You Travel Abroad?"
A: If you don’t have health insurance, or if your plan doesn't cover certain vaccines or shots, do the following:
A: Two of the main reasons health plans often pay for some or all of the costs tied to immunizations are they save lives and they save money. Specifically, they save insurance companies money by keeping people from developing illnesses and diseases that could cost them a lot more in the long run.
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