The Affordable Care Act and Immunization

Today, too many Americans don’t get the preventive health care they need to stay healthy, avoid or delay the onset of disease, lead productive lives, and reduce health care costs. Often because of cost, Americans use preventive services at about half the recommended rate.

The Affordable Care Act – the health insurance reform legislation passed by Congress and signed into law by President Obama on March 23 – will help make prevention affordable and accessible for all Americans by requiring health plans to cover preventive services and by eliminating cost sharing. According to new regulations released by the U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury, if an individual or family enrolls in a new health plan on or after September 23, 2010, then that plan will be required to cover recommended preventive services without charging a deductible, copayment or coinsurance. Expanding access to preventive care can improve health outcomes.

Expanding Coverage of Immunizations

Next year, an estimated 31 million people in new employer plans and 10 million people in new individual plans will benefit from the new prevention provisions under the Affordable Care Act.  The number of individuals in employer plans who will benefit from the prevention provisions is expected to rise to 78 million by 2013, for a total potential of 88 million Americans whose prevention coverage will improve due to the new policy. 

Individuals enrolled in these new group or individual health plans will have access to the vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) prior to September 2009 with no co-payments or other cost-sharing requirements when those services are delivered by an in-network provider.  These new health plans will be required to cover new ACIP recommendations made after September 2009 without cost-sharing in the next plan year that occurs one year after the date of the recommendation.

Many of the 98 million people currently enrolled in group health plans already have preventive services coverage including vaccines, although they may have co-payments or other cost-sharing requirements.  

Immunization Services for Children

Beginning September 23, 2010, children 0 through 18 years that are enrolled in new group or individual private health plans will be eligible to receive vaccines recommended by the ACIP prior to September 2009 without any cost-sharing requirements when provided by an in-network provider. 

  • Diphtheria, Tetanus, Pertussis
  • Haemophilus influenzae type b
  • Hepatitis A
  • Hepatitis B
  • Quadrivalent Human Papillomavirus vaccine for females
  • Inactivated Poliovirus
  • Influenza
  • Measles, Mumps, Rubella
  • Meningococcal
  • Rotavirus
  • Varicella

Vaccine Schedules: The latest child and adolescent immunization schedules can be found using the resources below:

Recommended Immunization Schedule for Infants and Young Children Ages 0 to 6 Years

Recommended Immunization Schedule for Children and Teens Ages 7 to 18 Years

Catch-up Immunization Schedule for Children and Teens Ages 4 Months Through 18 Years

Immunization Services for Adults

Adults 19 years and older who are enrolled in new group or individual private health plans will be eligible to receive vaccines recommended by the ACIP prior to September 2009 without any cost-sharing requirements when provided by an in-network provider as of September 23, 2010.

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

Vaccine Schedules: The latest adult immunization schedules can be found using the resources below:

Recommended Adult Immunization Schedule

Recommended Immunization Schedule for People with Health Conditions

Immunization Information for College Students and Young Adults 

Immunization Information for Seniors

Immunization Information for Pregnant Women

New Immunization Recommendations

In the table below are ACIP immunization recommendations that went into effect after September 23, 2009.   New health plans will be required to cover these ACIP recommendations without cost-sharing in the next plan year that occurs one year after the effective date of the recommendation.

VaccineRecommendationEffective Date of RecommendationPlan Year when Coverage is Required
Human Papillomavirus (HPV) VaccineThe new recommendation addresses vaccination with the bivalent (as opposed to quadrivalent) HPV vaccine for the first time; prior to January 8, 2010, the Advisory Committee did not make any recommendation on the bivalent vaccine.  The new recommendation also addresses vaccination of males for the first time; prior to January 8, 2010, the ACIP did not make any recommendation on the vaccination of males.

Effective January 8, 2010.

 

 

Plans and issuers are required to provide coverage without cost-sharing for this service exactly as described in the 2010 schedules in the first plan year (in the individual market, policy year) that begins on or after January 8, 2011.
Influenza VaccineAn expanded recommendation on influenza vaccine for all adults 19 to 49 years of age.Effective March 2, 2010.Plans and issuers will be required to provide coverage without cost-sharing for this service as described in the recommendation and in the 2011 schedules in the first plan year (in the individual market, policy year) that begins on or after March 2, 2011.
Combination Measles, Mumps, Rubella, and Varicella (MMRV) VaccineA new recommendation related to combination measles, mumps, rubella, and varicella vaccine.Effective May 7, 2010.Plans and issuers will be required to provide coverage without cost sharing for this service as described in the recommendation and in the 2011 schedules in the first plan year (in the individual market, policy year) that begins on or after May 7, 2011.
Meningococcal VaccineThe new recommendation only differs with respect to revaccination of individuals at increased risk.  The prior recommendation had addressed revaccination for certain individuals who had previously received meningococcal polysaccharide vaccine; the new recommendation extends this to certain individuals who had previously received meningococcal conjugate vaccine. 

Effective September 25, 2009.

 

 

 

Plans and issuers are required to provide coverage without cost-sharing for this service exactly as described in the 2010 schedules in the first plan year (in the individual market, policy year) that begins on or after September 25, 2010.
Pneumococcal VaccineAn expanded recommendation on pneumococcal vaccine.

Effective March 12, 2010.

 

Plans and issuers will be required to provide coverage without cost- sharing for this service as described in the recommendation and in the 2011 schedules in the first plan year  (in the individual market, policy year) that begins on or after March 12, 2011.

Seasonal Influenza Vaccine

This influenza season, children 6 months through 18 years, certain high-risk adults 19 through 49 years, and adults 50 years and older who are enrolled in new group and individual health plans will be eligible to receive the seasonal flu vaccine without cost-sharing when provided by an in-network provider. Beginning in the plan year that starts after March 2, 2011, all adults 19-49 years of age will be eligible to receive the seasonal flu vaccine with no cost-sharing requirements when provided by an in-network provider.

Strengthening Access to Immunization

In addition to expanding access to immunization under the preventive services rules, the Affordable Care Act includes the following immunization-related provisions:

  • Provides authority to states to purchase adult vaccines with state funds from federally-negotiated contracts. 
  • Reauthorizes the Section 317 Immunization Grant Program, which makes available federally purchased vaccines and grants to all 50 states, the District of Columbia, five large urban areas, and territories and protectorates to provide immunization services to priority populations.
  • Requires a General Accountability Office (GAO) study and report to Congress about Medicare beneficiary access to recommended vaccines under the Medicare Part D benefit. 

Background: U.S. Immunization Recommendations

The Advisory Committee on Immunization Practices (ACIP) consists of 15 experts in fields associated with immunization, who have been selected by the Secretary of the U. S. Department of Health and Human Services to provide advice and guidance to the Secretary, the Assistant Secretary for Health, and the Centers for Disease Control and Prevention (CDC) on the control of vaccine-preventable diseases. 

The role of the ACIP is to provide advice that will lead to a reduction in the incidence of vaccine preventable diseases in the United States, and an increase in the safe use of vaccines and related biological products.

Each year, the CDC updates the recommended immunization schedules for children, adolescents and adults to include any new vaccine recommendations made by the ACIP and approved by CDC. The immunization schedules give health care professionals information about the age when a vaccine should be given and how many doses are required for full protection.

Learn more about the ACIP, the process it uses to make recommendation, or information associated with particular immunizations at: www.cdc.gov/vaccines/recs/acip.

Posted on: September 14, 2010

Last updated: January 20, 2012