Richard H. Hughes, IV, Member of the Firm in the Health Care & Life Sciences practice, in the firm’s Washington, DC, office, authored an article in Health Affairs, titled “The ACA and IRA Require Coverage of Vaccines: But What About Travel Vaccines?”

Following is an excerpt:

The Affordable Care Act’s (ACA’s) requirement that private payers cover all vaccines recommended by the Centers for Disease Control and Prevention’s (CDC’s) Advisory Committee on Immunization Practices (ACIP) now applies to Medicaid and Medicare Part D thanks to the Inflation Reduction Act, ensuring that nine out of ten Americans have coverage of vaccines without cost sharing. The Centers for Medicare and Medicaid Services (CMS) has taken great care to emphasize that Part D plans must cover travel vaccines, but additional clarity is needed to provide equal access for the privately insured and Medicaid beneficiaries. This is confirmed by an earlier analysis that found the majority of privately insured Americans do not have health insurance coverage that includes travel vaccines.

Coverage without cost sharing (first dollar coverage) is an especially important tool for ensuring vaccine access. Non-coverage of unnecessary services and utilization management tools such as patient cost sharing may achieve a desired reduction in potential overuse of health care services. However, clinical preventive services intended to prevent the spread of disease, protect public health, and save health care dollars presumably should be incentivized. Any amount of out-of-pocket cost may deter a patient from opting to receive a vaccine. Moreover, it has been well-established that clarity of vaccine recommendations and coverage and out-of-pocket costs, are all essential to provider recommendations and patient acceptance of vaccines.

The ACA’s vaccine coverage requirement does not distinguish between travel vaccines and other vaccines. Under CMS’s implementing regulations, the ACA is interpreted to require coverage of those immunizations recommended by the ACIP for “routine use.” The rules go on to clarify that “routine use” means it is “listed on the Immunization Schedules of the Centers for Disease Control and Prevention.” Therefore, if the CDC places a vaccine on its immunization schedules, it must be covered.

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