If you want a covid-19 shot this fall, will your employer鈥檚 health insurance plan pay for it? There鈥檚 no clear answer.
Health and Human Services Secretary Robert F. Kennedy Jr., a longtime anti-vaccine activist, has upended the way covid vaccines are approved and for whom they鈥檙e recommended, creating uncertainty where coverage was routine.
Agencies within HHS responsible for spelling out who should get vaccinated aren鈥檛 necessarily in sync, issuing seemingly contradictory recommendations based on age or risk factors for serious disease.
But the ambiguity may not affect your coverage, at least this year.
鈥淚 think in 2025 it鈥檚 highly likely that the employer plans will cover鈥 the covid vaccines, said , a primary care doctor who is the population health leader for the management consultancy WTW and an assistant professor at Harvard鈥檚 T.H. Chan School of Public Health. They鈥檝e already budgeted for it, 鈥渁nd it would be a large administrative effort to try to exclude coverage for those not at increased risk,鈥 he said.
With so much in flux, it鈥檚 important to check with your employer or insurer about coverage policies before you roll up your sleeve.
Here鈥檚 what we know so far, and what remains unclear.
Q: How have the recommendations changed?
What used to be straightforward is now much murkier. Last year, the Moderna and Pfizer-BioNTech covid for anyone at least 6 months old.
This year, the recommendation by the Centers for Disease Control and Prevention is narrower. Although the vaccines are broadly recommended for adults 19 and older, they are no longer recommended for healthy or for 6 months through 17 years old.
Kennedy announced the changes in a , citing safety risks for young people and pregnant people .
But his claims have been widely disputed by experts in vaccines, pediatrics, and women鈥檚 health. An found that the secretary 鈥渕isrepresented scientific research to make unfounded claims about vaccine safety for pregnant people and children.鈥
In addition, recently announced changes to the vaccine approval framework have further chipped away at eligibility.
Moderna announced July 10 that the FDA had fully approved its 鈥 but approval is restricted to adults 65 and older, and for people from 6 months through 64 years old who are at increased risk of developing a serious case of covid.
Two other covid vaccines expected to be available this fall, and , are also restricted. They are approved for people 65 or older and those 12 to 64 who have underlying health conditions that put them at higher risk of developing severe covid.
Notably, covid vaccine is still approved or authorized for people 6 months of age and older without any restrictions based on risk factors for covid 鈥 at least for now. But the FDA could change that at any time, experts said.
Increasing restrictions 鈥渋s definitely the direction they are moving,鈥 said Jen Kates, a senior vice president at 麻豆女优 who authored a of vaccine insurance coverage rules. 麻豆女优 is a health information nonprofit that includes 麻豆女优 Health News.
HHS did not provide an on-the-record comment for this article.
Q: How might these changes alter my insurance coverage for the vaccine?
That鈥檚 the big question, and the answer is uncertain. Without insurance coverage, people could owe for the shot.
Most private health plans are required by law to cover recommended vaccines, whether for covid, measles, or the flu, without charging their members. But that requirement kicks in after the shots are 鈥 the Advisory Committee on Immunization Practices 鈥 and adopted by the CDC director, according to the 麻豆女优 analysis. The committee hasn鈥檛 yet voted on covid vaccine recommendations for this fall. Its next meeting is expected to occur in August or September.
Still, employers and insurers can opt to cover the vaccines on their own, as many did before the law required them to do so. But they may require people to pay something for it.
In addition, the narrower recommendations from different HHS agencies might result in some health plans declining to pay for certain categories of people to get certain vaccines, experts said.
鈥淚 don鈥檛 think an employer or insurer would deny coverage,鈥 Kates said. 鈥淏ut they could say: You have to get this product.鈥
That could mean a 45-year-old with no underlying health conditions raising their covid risk might have to get the Pfizer shot rather than the Moderna version if they want their health plan to pay for it, experts said.
In addition, up to 200 million people may qualify for the vaccines because they have health conditions such as asthma or diabetes that increase their risk of severe disease, according to a by FDA officials in the New England Journal of Medicine.
Health care professionals can help people determine whether they qualify for the shot based on health conditions.
Tina Stow, a spokesperson for AHIP, which represents health plans, said in a statement that plans will continue to follow federal requirements for vaccine coverage.
Q: What are the options for people who are pregnant or have children they want to have vaccinated?
Many parents are confused about getting their kids vaccinated, according to a released on Aug. 1. About half said they don鈥檛 know whether federal agencies recommend healthy children get the vaccine this fall. Among the other half, more said the vaccine is not recommended than recommended.
Meanwhile, Kennedy鈥檚 recommendation that healthy children not get vaccinated has a notable caveat: If a parent wishes a child to get a covid vaccine and a health care provider recommends it, the child can receive it under the 鈥溾 model, and it should be covered without cost sharing.
Some policy experts point out that this is the way care for kids is typically provided anyway.
鈥淥utside of any requirements, vaccines have always been provided through shared decision-making,鈥 said Amanda Jezek, senior vice president of public policy and government relations at the Infectious Diseases Society of America.
There鈥檚 no similar allowance for pregnant people. However, even though Kennedy has stated that covid vaccines are no longer recommended for healthy pregnant people, pregnancy is one of the underlying that put people at high risk for getting very sick from covid, according to the CDC. That could make pregnant people eligible for the shot.
Depending on the stage of someone鈥檚 pregnancy, it could be difficult to know whether someone should be denied the shot based on their condition. 鈥淭his is uncharted territory,鈥 said Sabrina Corlette, co-director of Georgetown University鈥檚 Center on Health Insurance Reforms.
Q: How will these changes affect access to the vaccine? Will I still be able to go to the pharmacy for the shot?
鈥淚f far fewer are expected to be vaccinated, fewer sites will offer the vaccinations,鈥 Levin-Scherz said. This could be an especially notable hurdle for people looking for pediatric doses of a covid vaccine, he said.
In addition, pharmacists鈥 authority to administer vaccines depends on several factors. For example, in they can administer shots that have been approved by the FDA, while in others the shots must have been recommended by the ACIP, said Hannah Fish, senior director of strategic initiatives at the National Community Pharmacists Association. Since ACIP hasn鈥檛 yet recommended covid shots for the fall, that could create a speed bump in some states.
鈥淒epending on the rules, you still may be able to get the shot at the pharmacy, but they might have to call the physician to send over a prescription,鈥 Fish said.
Q: What do these changes mean long-term?
It鈥檚 impossible to know. But given Kennedy鈥檚 vocal skepticism of vaccines and his embrace of long-disproven theories about connections between vaccines and autism, among other things, medical and public health professionals are concerned those views will shape future policies.
鈥淭he recommendation changes that were made with respect to children and pregnant women were not necessarily made in good science,鈥 Corlette said.
It鈥檚 already a challenge to convince people they need annual covid shots, and shifting guidelines may make it tougher, some public health experts warn.
鈥淲hat鈥檚 concerning is that this could even further depress the uptake of the covid vaccines,鈥 Jezek said.
