Vaccine Coverage, Pricing, and Reimbursement in the U.S. | KFF

Introduction

COVID-19 vaccines are progressing through Phase 3 trials, with the U.S. government investing $10 billion in research, development, manufacturing, and distribution. The government has pre-purchased hundreds of millions of doses, which will be given to providers free of charge under the CDC’s COVID-19 vaccination program. Patients will not have to pay for the COVID-19 vaccine, thanks to changes in laws and regulations governing vaccine coverage. This article explores how vaccines are covered and paid for in various government programs and insurance types. It also discusses specific policies for the COVID-19 vaccine and general information about CDC vaccine recommendations.

Medicare Coverage

Medicare covers immunizations for more than 60 million people aged 65 and older, as well as young adults with long-term disabilities. Vaccines for influenza, pneumococcal disease, and Hepatitis B are covered under Medicare Part B, while other commercially available vaccines are covered under Medicare Part D. The costs for vaccines vary, and patients may have to pay a percentage of the cost or a copayment depending on their coverage.

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Private Health Insurance

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Approximately 55% of Americans have private health insurance, primarily through employer-sponsored plans. ACA-compliant plans must cover ACIP-recommended vaccines without cost-sharing. However, short-term plans, which are not subject to federal coverage standards, may require cost-sharing for vaccines. Vaccine prices in the private market are not regulated, but economic analysis in ACIP recommendations may help reduce prices.

Vaccines for Children Program

The Vaccines for Children (VFC) Program provides free vaccines for eligible children. Children under 19 years old who are Medicaid eligible, uninsured, or American Indian/Alaska Native can receive vaccines through this program. VFC covers recommended vaccines, and participating healthcare providers may charge for administration fees.

Medicaid and CHIP Coverage

Medicaid and CHIP provide health insurance coverage for low-income Americans. Immunization coverage varies by age, eligibility pathway, and state. ACA-compliant Medicaid plans must cover ACIP-recommended vaccines without cost-sharing. The coverage of COVID-19 vaccines for Medicaid recipients is subject to specific requirements during the public health emergency and enhanced federal funding period.

Section 317 of the Public Health Services Act

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Section 317 provides vaccines to uninsured adults and other eligible adults. Participation in this program is discretionary, and coverage depends on available funds. Uninsured adults can receive free immunizations through state or local health departments. The CDC negotiates vaccine prices, resulting in discounts ranging from 24% to 59% off the list price.

Department of Veterans Affairs

The Department of Veterans Affairs (VA) provides healthcare to eligible veterans, and preventive care, including immunizations, is free of cost-sharing. Vaccine prices for the VA are negotiated, resulting in an average discount of about 40% off the list price.

Implications

The focus on COVID-19 vaccines has raised awareness of vaccine coverage, pricing, and cost-sharing. While changes have been made to ensure access to the COVID-19 vaccine without cost-sharing, universal standards for vaccine coverage are lacking for other vaccines. Vaccine prices are determined through a combination of negotiations, legal formulas, and state reimbursement decisions. The government has already purchased millions of COVID-19 vaccine doses, but the ultimate demand and pricing for these vaccines remain uncertain. In the future, COVID-19 vaccines may be covered under existing programs and insurance types. Policymakers can use existing rules and pricing strategies to address concerns about vaccine costs.

Source: https://amajon.asia
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