There’s been some news out there recently about vaccines. At the CDC, an advisory panel has reversed a recommendation for hepatitis B vaccinations beginning at birth. Meanwhile, at HHS, a whistleblower has revealed that they’re planning a complete overhaul of the current childhood vaccine schedule, removing routine immunizations against rotavirus, flu, and chicken pox.
In a predictable move, several states have already announced that they do not intend to follow the new recommendations, and that they are going to issue their own guidance instead.
Regardless of where you stand on the vaccine debate itself, one thing is obvious: the situation is getting messy. Parents are wondering not only which vaccines they should approve, but also which vaccines will even be available and covered by their health plan for free. It’s a valid question, but unfortunately, the answer is equally messy: it depends.
Coverage of preventive care is mandated by the ACA, but the definition of preventive care has always seemed a bit slippery to many. It actually isn’t: health plans tend to use the USPSTF’s A and B Recommendations to determine what is considered “preventive care.” The task force’s vaccine recommendations generally follow CDC guidance.
With states now getting into the business of issuing vaccine guidance, what are health plans likely to do? Here are some things to remember:
- If you’re on a self-funded health plan — and most people with employer-sponsored coverage are — your plan is exempt from any state mandates that may be enacted. However, the health plan itself can decide to cover vaccinations above and beyond CDC guidance, and precedent already exists for health plans doing the same with other preventive care.
- If you have a major carrier’s logo on your insurance card, that does not mean your plan isn’t self-insured. Many self-insured plans contract with major carriers for claims administration and provider network definitions.
- If you’re on an individual plan (regardless of whether you bought it through the exchange), your coverage is subject to state mandates; and for cost reasons it’s likely to strictly interpret those mandates.
- Some smaller businesses (under 50 employees, except in California, Colorado, and New York where it’s under 100) have fully-insured coverage that is subject to both ACA guidelines and state mandates. You can expect these plans to abide by them, though they may imitate individual policies and apply strict interpretations.
- Occasionally, larger businesses may have “fully insured” coverage instead of self-funded coverage. In that case, your health coverage will also be subject to both ACA guidelines and state mandates.
What’s my best advice, then? I can give it in one word:
Ask.
The person who handles benefits in your human resources office should know what type of plan you have. If they don’t, their insurance broker definitely will know.
Remember that health coverage is a contract, and that contract will specifically define the type of plan. It’s one of the basic provisions in the contract, since self-insured vs. fully insured is also used to determine who, exactly, comes up with the money to pay the claims.
Your health coverage is controlled by that contract, not by press releases or government recommendations. If you or your child are covered by a health plan, you have the right to see that plan’s schedule of benefits, a basic provision of that document. Knowing what’s spelled out there is the key to making informed decisions about your and your family’s preventive care.