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The Impact of Health Care Reform
Preventive Health Services including Vaccines are covered under the Affordable Care Act (ACA)
As of January 1, 2014, the Affordable Care Act (ACA) requires certain private insurance plans to cover a range of clinical preventive services without any cost-sharing, such as copays, deductibles, or coinsurance, for patients receiving these services by an in-network provider.1 This is true even if the patient has not yet met their yearly deductible.
These requirements apply to privately insured plans — including individual, small group, large group, and self-insured plans in which employers contract administrative services to a third-party payer — with the exception of those plans that maintain “grandfather” status.2
In order to have been classified as “grandfathered”, plans must have been in existence prior to March 23, 2010, and must not have made significant changes to their coverage (eg, increasing patient cost-sharing, cutting benefits, or reducing employer contributions.)2
Each year, the CDC’s Advisory Committee on Immunization Practices (ACIP), in conjunction with the American Academy of Family Physicians (AAFP) and the American Academy of Pediatrics (AAP), develop recommendations for routine use of vaccines in children, adolescents, and adults.1
The ACA mandates that non-grandfathered private insurance plans cover all vaccinations recommended by the ACIP with no cost-sharing for those patients who are within the scope of the ACIP recommendation when the vaccine is administered by an in-network provider.2, 3 (For new ACIP recommendations made after September 2009, the requirement is effective in the next plan year that occurs 1 year after the date of the recommendation.)4
The coverage information provided here is general in nature and is subject to change. It is not intended to be exhaustive, or replace the guidance of a qualified reimbursement advisor, and does not constitute legal or reimbursement advice. The use of the information presented here is not a guarantee of coverage or payment. Whether reimbursement is available and the amount of reimbursement for a specific patient can depend on a variety of factors. You should contact the patient's insurer for coverage details. Merck does not guarantee or ensure the timeliness or appropriateness of this information for your particular use given the frequent changes in public and private payer billing.
A resource explaining coverage for preventive health benefits under the Affordable Care Act, including vaccinations under a non-grandfathered private health plan
Download a resource to help remind your patients they need to schedule their annual preventive health appointment
- American Academy of Family Physicians (AAFP). AAFP details ACA’s 2014 preventive services; offers clinical, coding resources. AAFP News. http://www.aafp.org/news/inside-aafp/20140107acaresources.html. Accessed March 18, 2015.
- Henry J Kaiser Family Foundation. Preventive services covered by private health plans under the Affordable Care Act. October 2014. http://kff.org/health-reform/fact-sheet/preventive-services-covered-by-private-healthplans/. Accessed March 18, 2015.
- National Women’s Health Resource Center, Inc. Preventive services covered under the Affordable Care Act. Healthy Women.org. http://www.healthywomen.org/content/article/preventive-services-covered-underaffordable-care-act?context=print/node/8051&context_ title=Preventive Services Covered Under the Affordable Care Act. Accessed March 18, 2015.
- US Dept of Health and Human Services. The Affordable Care Act and immunization. http://www.hhs.gov/healthcare/facts/factsheets/2010/09/The- Affordable-Care-Act-and-Immunization.html. Accessed June 26, 2015.