If you’re in good health and plan to get a Covid shot this fall, you might end up with an unwelcome surprise: a bill.
The Food and Drug Administration is expected to approve the next round of Covid shots soon, but only for a smaller, high-risk group — adults 65 and older and people with underlying health conditions. The Centers for Disease Control and Prevention is likely to follow suit, limiting its recommendation on who should get the shots to the same groups. (The CDC currently recommends Covid vaccination for everyone 6 months and older.)
The change, experts say, could affect what insurers are willing to cover for everyone else who doesn’t fall under a high-risk group.
By law, most health insurance plans are required to fully cover vaccines recommended by the CDC and its outside advisory committee, the Advisory Committee on Immunization Practices (ACIP).
For those who don’t fall under the CDC’s new recommendations, experts say coverage would depend entirely on their insurance — with some deciding to fully cover the shot, others requiring a copay and some not covering it at all.
Without insurance, a Covid shot can cost up to $140, according to the CDC’s vaccine price list.
“It could very well get confusing,” said Dr. William Schaffner, an infectious disease expert at Vanderbilt University Medical Center in Nashville, Tennessee, and an adviser to ACIP. Whether you’re able to get a free shot “may greatly depend on which company with which you have your insurance.”
Who can get a Covid vaccine?
Under the expected recommendations from the CDC, healthy children and adults won’t be barred from getting the Covid vaccine, said Dorit Reiss, a vaccine policy expert at UC Law San Francisco.
“It’s legal to give a vaccine off-label,” Reiss said, referring to when a doctor prescribes a drug for something different than what the FDA approved it for, “and insurance companies can choose to cover them.”
A spokesperson for AHIP, a health insurance industry trade group, said that every individual insurer will come up with its own policy following the CDC’s final guidance.
The CDC’s list of conditions that put a person at high risk for severe illness from Covid is extensive, and includes cancer, heart disease and lung conditions as well as physical inactivity and depression.
Insurers also take into account clinical recommendations from outside medical organizations, like the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics, the spokesperson said.
On Tuesday, the AAP, which has expressed its disapproval for Health Secretary Robert F. Kennedy Jr.’s vaccine decisions, released its own recommendations supporting Covid vaccinations for children.
Most people are also unlikely to notice changes to their insurance coverage overnight — if there are any, according to the AHIP spokesperson.
For private plans — including Obamacare plans — any changes stemming from ACIP meetings could likely only be implemented in the next benefit year, typically Jan. 1, the spokesperson said. That means it’s possible that people who get a shot before then might be covered. Medicare and Medicaid plans are required to follow ACIP recommendations immediately upon the CDC director’s signature. Covid vaccines have also already been factored into insurers’ plans for this year.
In an emailed statement, a spokesperson for Blue Cross and Blue Shield said that “each independent Blue Cross and Blue Shield plan will make their own coverage decisions.”
Covid and flu shots
The changes could affect people planning to get their Covid and flu vaccines at the same time.
Schaffner, of Vanderbilt, said some people choose to get their Covid and flu shots at the same time, but there are concerns that some could be turned away due to the anticpated change in recommendations.
He added that misinformation about who is able to get the Covid shots may also discourage people from getting either vaccine.
“I think we have to reassure people, particularly those at high risk, that the vaccine will be available to them,” he said.
Rick Gates, Walgreens’ chief pharmacy officer, said its pharmacists usually determine whether a patient has coverage before a vaccine is administered.
Because of this, it’s unlikely anyone would be hit with a surprise bill due to new CDC recommendations, he said, adding that the patient would first be told whether the vaccine is fully covered, a copay is required or the patient must pay entirely out of pocket.
Gates said that people are already coming in for their flu shot, but many seem to be holding off on the Covid shot until the updated version is available. During last year’s respiratory virus season peak, he said, more than 50% of patients got both shots at once — a number that has grown over the past two to three years.
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