Does My Health Insurance Cover Vaccinations?

Under the Affordable Care Act (ACA), all ACA health plans and most private insurance plans are required to cover many common vaccines, including those for measles, mumps, shingles and the flu. The COVID-19 vaccine and boosters are currently free to everyone.

If you don’t have insurance, free vaccines may be available through a community health center or your local or state health department. For those with Medicaid, vaccine costs are covered if you’re under 21 or for adults who qualify for all essential health benefits (EHB).

On This Page

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  Which Vaccines are Covered by Insurance?

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  How Do I Know if My Insurance Covers Vaccinations?

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  Where Can I Find Free and Low-Cost Vaccines?

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  How Much Do Vaccines Cost With Medicaid?

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  How Much Do Vaccines Cost Without Insurance?

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  FAQs

Which Vaccines are Covered by Insurance?

Private healthcare plans will cover most common vaccines, like chickenpox, influenza and shingles. Below is a table showing the vaccination rates by type of vaccine and insurance coverage from 2015 to 2018.

Source: MACPAC.gov.

Below is a brief breakdown of each illness that vaccines would help prevent.

• Hepatitis A: Highly contagious liver infection spread by contaminated food, water or contact with an infected person. Symptoms may include nausea, fatigue, abdominal pain, low-grade fever and loss of appetite.
• Hepatitis B: Severe liver infection spread commonly by exposure to infected body fluids. Symptoms may include abdominal pain, dark urine and yellowing of the eyes.
• Herpes Zoster (shingles): Reactivated virus after having chickenpox that causes a painful rash. Initial spread through direct contact or aerosolized particles. Other symptoms may include headache, fever, upset stomach and chills. Shingles is very severe for adults.
• Human Papillomavirus (HPV): Sexually transmitted infection (STI) characterized by warts on different parts of the body depending on the strain. HPV can lead to cancer. There typically aren’t other symptoms.
• Influenza (flu): Common virus spread primarily through droplets from people sneezing, talking or coughing who are infected. Symptoms include chills, fever, muscle aches, congestion, cough, runny nose, fatigue and headaches.
• Measles: Viral infection spread through coughing or sneezing. Symptoms include a runny nose, cough, sore throat, inflamed eyes, fever and a skin rash. Can be serious for small children.
• Mumps: Viral infection that affects the salivary glands spread through saliva. Symptoms include swollen salivary glands, headache, fever, loss of appetite and fatigue.
• Rubella: Viral infection spread through direct contact with infected mucous or saliva or through coughing or sneezing. Symptoms include a rash, headaches and mild fever.
• Meningococcal: Bacterial infection spread by sharing respiratory and throat secretions such as saliva. Symptoms include fever, chills, cold hands and feet, vomiting, rapid breathing, diarrhea, pain in joints, abdomen and/or muscles and a dark purple rash. The Centers for Disease Control (CDC) recommends that young adults 16 through 23 years old and adolescents should receive a serogroup B meningococcal vaccine.
• Pneumococcal: Bacterial infection that can cause pneumonia and strep throat spread by direct contact with infected saliva and mucous.
• Tetanus: Bacterial infection that releases a nerve toxin spread by contaminated soil, dust, and manure particles entering through the skin. Symptoms include difficulty swallowing, painful muscle spasms in the jaw and neck, high blood pressure, fever, sweating and nervous system dysfunction. Could be potentially fatal.
• Diphtheria: Serious bacterial infection spread by coughing and sneezing. Symptoms include fever, sore throat, weakness and swollen lymph nodes.
• Pertussis (whooping cough): Bacterial infection spread through coughing and sneezing. Symptoms include a “whoop” sounding cough, sneezing, running nose and nasal congestion.
• Varicella (chickenpox):  Virus that causes a painful rash spread through direct contact or by aerosolized particles. Other symptoms may include headache, fever, upset stomach and chills. Can be severe for adults.

When it comes to your health, prevention matters. The illnesses listed above are easily preventable by getting a vaccine.

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How Do I Know if My Insurance Covers Vaccinations?

All health insurance plans and most private insurance plans are required to cover many common vaccines under the Affordable Care Act (ACA), regardless of whether your plan is HMO, EPO, PPO or POS. Keep in mind that coverage for vaccines may vary if obtained out-of-network.

Copayments, coinsurance and deductibles should not apply if the vaccine was administered by an in-network provider.

However, a copayment may be necessary if your employer purchased your health coverage before the ACA was enacted in 2010. Your health insurance provider can confirm which vaccines are covered. Health plans in the next year are required to cover new vaccine recommendations.

Where Can I Find Free and Low-Cost Vaccines?

Adults without insurance can get free vaccines through a community health center through Section 317 or from their local or state health department. Section 317 allows the federal government to subsidize the cost of vaccines for adolescents, children and adults.

The CDC negotiates prices for vaccines purchased through Section 317, as it does with the Vaccines for Children Program (VCP). The CDC price for vaccines averages about 40% less than the list price (the manufacturer's suggested retail price). This discount will vary, sometimes ranging from 24% to as high as 59%. Vaccinations are available from pharmaceutical companies’ patient assistance programs, as well.

The annual budget for Section 317 is fixed — this means federal funding will not increase to keep pace with the rising cost of vaccines over time. Funding limitations may deter uninsured individuals from getting flu vaccines. In 2018, 40% of adults between 18 to 64 with insurance obtained the flu vaccine, while only 16% of uninsured adults get vaccinated.

Vaccination against COVID-19 is currently free regardless of insurance status — however, this may be changing soon.

How Much Do Vaccines Cost With Medicaid?

Medicaid in most states will cover some adult immunizations. Children under 21 who are eligible for the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit receive all ACIP-recommended vaccines. The Vaccines for Children (VFC) program provides free vaccines to children enrolled in Medicaid, the underinsured or uninsured or an American Indian or Alaska Native through age 18.

Through the VFC program, the CDC purchases vaccines at a discounted rate and distributes them to territorial public health agencies and state health departments. These grantees then distribute vaccines for free to public healthcare clinics and private physicians' offices registered as VFC providers. Healthcare providers may then charge an administration fee that can vary by clinic and state.

Medicaid pays the vaccine administration fee for children who are enrolled in Medicaid. If the child is uninsured or underinsured and enrolled in VFC, the parents are billed.

Whether or not you have Medicaid, you can still get a free COVID-19 vaccine.

Does CHIP Cover Vaccines?

The Children's Health Insurance Program (CHIP) covers vaccines. CHIP primarily serves children with parents who don’t qualify for Medicaid but can’t afford a health insurance plan through the traditional marketplace. CHIP is required to cover “age-appropriate” vaccines, such as a DTaP shot at two months and subsequent boosters throughout the year.

If a state has a separate CHIP program, vaccines can only be purchased using CHIP state and federal matching funds. Children enrolled in the CHIP program cannot have vaccines purchased through the VFC. States can purchase vaccines for children enrolled in the CHIP program in two ways:

• Purchase vaccines using the CDC
• Purchase vaccines through the private sector

How Much Do Vaccines Cost Without Insurance?

The cost of a vaccine is going to vary depending on the type of vaccine and if the vaccine is for a child or an adult. Below is a list of vaccines and what they cost out-of-pocket for those without insurance.

Source: Cal Poly Humboldt

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