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Resources for Adult Vaccination Insurance and Payment

Many healthcare professionals want to immunize their patients with recommended vaccines. These resources are designed as a starting point to help your practice better understand vaccine coverage.

Private Insurance Vaccine Coverage

All Health Insurance Marketplace plans and most other private insurance plans must cover the following list of vaccines without charging a copayment or coinsurance when provided by an in-network provider. This is true even for patients who have not met a yearly deductible. Doses, recommended ages, and recommended populations for these vaccines vary:

A new recommendation for serogroup B meningococcal vaccination of those age 16 through 23 years was published in the MMWR dated October 23, 2015. Health plans are required to cover new vaccine recommendations without cost-sharing in the next plan year that occurs one year after this date. Patients should check with their insurance provider for details on whether there is any cost to them for this vaccine.

  • Hepatitis A
  • Hepatitis B
  • Herpes Zoster
  • Human Papillomavirus
  • Influenza
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Tetanus, Diphtheria, Pertussis
  • Varicella

Check with your patient’s insurance provider for details of coverage. Under the Affordable Care Act, insurance plans that cover children now allow parents to add or keep adult children on their health insurance policy until they turn 26 years old.

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Medicare Coverage and Payment

Medicare covers initial pneumococcal vaccine and different, second pneumococcal vaccine one year after the first is administered, effective February 2, 2015. See Modifications to Medicare Part B Coverage of Pneumococcal Vaccinations[3 pages].

Medicare Part B will pay for the following vaccines:

  • Influenza (flu) vaccine
  • Pneumococcal vaccines
  • Hepatitis B vaccines for persons at increased risk of hepatitis
  • Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition, such as rabies and tetanus

The Medicare Immunization Quick Reference[6 pages] provides billing information about influenza, pneumococcal, and hepatitis B vaccines.

Medicare Part D plans identify covered vaccines through formularies. Part D plan formularies must include all commercially available vaccines (except those covered by Part B). A new preventive vaccine may not specifically appear in the formulary, but the plan may still cover the vaccine. Contact the plan to find out about coverage.

Medicare Part D or Medicare Advantage Plan Part C that offers Medicare prescription drug coverage may also have coverage for

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Make sure adults looking for a vaccine provider can find you. Register your practice or clinic with the HealthMap vaccine finder.

  • Zoster
  • MMR
  • Tdap

Learn more about vaccine payments under Medicare Part D. [2.1 MB, 8 pages]

 

Medicaid Coverage

Most State Medicaid agencies cover at least some adult immunizations but not all offer vaccines at the ACIP standards.

Learn more about Medicaid and vaccines.

 

Military Insurance

For your patients who serve in the military or are a military dependent eligible for TRICARE, vaccines are covered according to the CDC recommended schedule.

 

Patients without Insurance

If your patients do not currently have any health insurance, let them know that they can visit www.HealthCare.gov to learn more about health coverage options.

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