How can someone know if their health plan includes coverage for vaccinations according to DPH guidelines?
Most health plans in Massachusetts cover vaccinations. Individuals should review their plan documents, contact their employer’s human resources representative, or call their health plan’s Member Services (available online or by calling the telephone number on the member ID card) to understand whether their health plan includes coverage for vaccinations and which ones it covers.
How can someone know if their health plan is required to cover vaccinations according to DPH guidelines?
The Vaccination Bulletin applies to fully insured individual and group health benefit plans delivered, issued, or renewed to individuals in the Commonwealth. This also includes health plans purchased through the Massachusetts Health Connector (e.g., all ConnectorCare Health Plans). Plans offered by the Group Insurance Commission (“GIC”), which provides health coverage for many Commonwealth state employees, and those covered by the MassHealth Program (Massachusetts’ Medicaid program) will also cover vaccinations according to DPH guidelines; however, these programs are not subject to DOI jurisdiction and questions should be directed to GIC and/or MassHealth, as applicable.
The Vaccination Bulletin does not apply to:
- Many large employers self-fund employee health benefits, meaning that they pay the benefits from their own resources rather than buying a fully insured health plan from an Insurance Carrier. Self-funded health plans are exempt from state-mandated benefits, including the DOI’s vaccine coverage oversight, and the DOI does not have any jurisdiction over these federally-regulated plans. In some instances, self-funded plans may include these benefits, so you should check with your employer or health plan for specific details of your plan’s benefits.
- Health plans that are issued in another state and many federal government health coverage programs, including Medicare or TriCare. These plans are still required to cover any vaccinations as recommended by the federal Centers for Disease Control (“CDC”), or by the Advisory Committee on Immunization Practices (“ACIP”), as required by the federal Affordable Care Act, but you should contact the specific plan for additional information.
- Individuals without insurance. While Massachusetts law requires residents to have health insurance, if residents who do not have insurance wish to receive vaccinations, they should check with their local health department or community health center.
What vaccination services are available to me/my patient in accordance with the DOI/DPH Vaccination Bulletin?
The Vaccination Bulletin explains that Insurance Carriers are expected to provide coverage for those vaccines that fall within DPH guidelines. The DPH guidelines currently include all routinely recommended vaccines, e.g., those recommended by the federal CDC or ACIP, and national medical professional societies such as the American Academy of Pediatrics and American College of Family Physicians. The Vaccination Bulletin explains how fully insured health plans are expected to cover the cost to administer the vaccines, without cost-sharing and without the use of any utilization management.
Are Insurance Carriers allowed to limit coverage to vaccinations on their prescription drug formularies?
Yes, Insurance Carriers may decide to cover only certain brands of vaccinations on their prescription drug formularies. They can continue to cover certain brands, provided that there is at least one product on the plan formulary that will address each item on the DPH recommended guidelines for vaccines.
Are Insurance Carriers allowed to place limits on who can provide vaccinations to their members?
Yes. Insurance Carriers typically have a closed network of providers who provide non-emergency services (such as in-network primary care doctors), and Insurance Carriers may require their members to access non-emergency vaccines from only those health care practitioners or pharmacies that are part of their closed networks. An Insurance Carrier is not required to have all health providers or facilities within its network, so long as the Insurance Carrier has networks that the DOI has determined to provide adequate access to obtain vaccinations from in-network providers
When are people in fully insured plans eligible for vaccinations?
The services are to be covered by Massachusetts fully insured health plans when provided in accordance with DPH guidelines.
Which vaccinations are covered by the DOI/DPH Vaccination Bulletin?
The Vaccination Bulletin applies to routine vaccinations intended to prevent disease according to DPH guidelines. Insurance Carriers are expected to clearly disclose how individuals can access vaccinations. Before receiving services, members of a health plan should always check their plan network requirements, including any out-of-network benefits available and their associated costs.
Are there vaccinations that may not fall under DPH guidelines?
There may be vaccinations that do not fall within specified DPH guidelines, but which are, for example, clinically recommended for travel to specific places or under special circumstances, such as Chikungunya, Japanese encephalitis, typhoid, and yellow fever. Vaccines that are not addressed under DPH guidelines may be covered when medically appropriate, but such vaccines may be subject to plan cost-sharing, utilization management requirements, or benefit limitations. Individuals should review their plan documents or contact their employer’s human resources representative or their health plan’s Member Services to understand whether their health plan includes coverage for such vaccinations.
Will I be able to receive the same vaccination services if I change health plans?
If an individual is receiving vaccination benefits from a Massachusetts-issued fully insured health plan, that plan is required to present information that explains how coverage for vaccination services may change if the individual changes to a different health insurance plan. Keep in mind that in Massachusetts, you can only switch individual health plans during the annual open enrollment process unless you have a qualifying event, such as losing your job or having a baby. When switching health plans:
- If an individual switches coverage to a fully insured plan that requires the use of in-network providers, the individual may be required to switch to a provider that is available in the network of the new plan to be covered.
- If an individual switches coverage to a health plan that is not subject to the Vaccination Bulletin, such as a self-insured plan, the individual may not have certain vaccination benefits covered under the new health plan.
How are Insurance Carriers expected to pay for vaccines?
The Vaccine Purchase Trust Fund directly pays for pediatric vaccines for those 18 and under through an assessment of insurance carriers. Insurance Carriers are expected to directly pay for all adult vaccines and for pediatric vaccines not administered through the Vaccine Purchase Trust Fund, including the cost to administer those vaccines. Provided that the vaccination is covered under DPH’s guidelines or recommended by the CDC or the ACIP, the member should not have any cost-sharing for the vaccine.
May Insurance Carriers do medical necessity reviews for vaccinations?
Insurance Carriers are expected to cover vaccinations according to DPH guidelines for persons in Massachusetts-issued fully insured health plans and may not use any utilization management practices that would delay access to vaccines under the DPH guidelines.
Based on the patient’s medical conditions, individuals or their providers may also request that vaccinations be approved for situations that are not consistent with DPH guidelines. In these situations, for fully insured health plans, Insurance Carriers are required to follow managed care practices to review requests for services according to medical necessity criteria established by a health plan’s medical director.
Insurance Carriers are required to review all prior approval requests and either approve or deny a completed request within two (2) business days. If a request is denied, the Insurance Carrier is to issue an adverse determination letter that explains the medical necessity reasons for a denial and the patient’s right to appeal the decision. If there are any questions about the appeal process, including about requests for expedited appeals, the Office of Patient Protection can be reached by e-mail at HPCOPP@mass.gov.
Questions and Complaints
If there are additional questions about vaccinations, please contact Niels Puetthoff, Director, Bureau of Managed Care, Division of Insurance, at niels.puetthoff@mass.gov. Complaints may be filed online.