Key points
Making sure your adult patients receive recommended vaccines is important because immunity from childhood diseases can wear off over time. Adults are also at risk for different diseases, and vaccination is one of the most convenient and safe preventive care measures available. These resources can help your practice better understand insurance coverage for vaccines.
Private Insurance Coverage
All Health Insurance Marketplace plans, and most other private insurance plans, must cover routinely recommended vaccines without charging a copayment or coinsurance when provided by an in-network provider. This applies for patients who have not met their yearly deductible. Doses, recommended ages, and recommended populations for these vaccines vary. Private health plans are required to cover new vaccine recommendations in the next plan year; however, some insurance plans may cover them in the current plan year.
Check with your patients' insurance providers for coverage details. Under the Affordable Care Act, insurance plans that cover children allow parents to add or keep adult children on their health insurance policy until they are 26 years old.
Medicare Coverage
Medicare Part B will pay for the following:
- Hepatitis B vaccines for persons at increased risk for hepatitis
- Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition, such as rabies or tetanus
Medicare Part D plans make all adult vaccines recommended by the Advisory Committee on Immunization Practice (except those covered by Part B) available at no cost, including:
- Respiratory Syncytial Virus (RSV)
- Zoster (Shingles) vaccine
Even if a particular drug plan's formulary does not list all Part D vaccines, it must provide access when a physician prescribes a Part D vaccine.
Here's where to find Medicare Coverage Options.
Medicaid Coverage
Most adults with Medicaid coverage are guaranteed, at no cost, vaccines recommended by the Advisory Committee on Immunization Practice.
Military Insurance
Your patients who serve in the military or are a military dependent are eligible for TRICARE. Under TRICARE, vaccines are covered according to the CDC recommended schedule.
Patients without Insurance
If your patients do not have any health insurance, let them know they can visit www.HealthCare.gov to learn more about health coverage options.
You can also refer patients to federally funded health centers, which provide preventive services including vaccines, and may offer sliding fees based on income. Health departments may have additional information on where to go for free and low-cost vaccines. Locations might include community centers, schools, or religious centers.