The ACA and IRA mandate vaccinations, but what about travel vaccines?

The Affordable Care Act (ACA) requirement that private payers cover all vaccines recommended by the Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization (ACIP) is due to the Inflation Reduction Act. now applies to Medicaid and Medicare Part D.9 out of 10 Americans Cover vaccines without sharing costsThe Centers for Medicare and Medicaid Services (CMS) have taken great care to emphasize that Part D plans must cover travel vaccines, but they do not offer equal coverage to private insurance and Medicaid beneficiaries. Further clarification is needed to provide access. This is confirmed by previous analysis that the majority of privately-insured Americans do not have health insurance that includes travel vaccines.

Compensation without cost-sharing (the first $1 of compensation) is a particularly important tool for ensuring access to vaccines. By eliminating unnecessary services and utilization management tools such as patient cost sharing, potential overuse of health services can be reduced to desired levels. However, clinical preventive services aimed at preventing the spread of disease, protecting public health, and saving healthcare costs should probably be encouraged. High out-of-pocket costs can discourage patients from choosing to get the vaccine. Furthermore, it is well established that clarity of vaccine recommendations and coverage and out-of-pocket costs are all essential for provider recommendations and patient acceptance of vaccines.

The ACA’s vaccination requirements do not distinguish between travel vaccines and other vaccines. Under the CMS Code of Practice, the ACA is interpreted as having to cover immunizations recommended by the ACIP for “routine use”. The regulations clarify that “regular use” means “as listed in the Centers for Disease Control and Prevention’s immunization schedule.” So if the CDC places a vaccine on its immunization schedule, it should be covered.

CDC Travel Vaccine Recommendation “Grey Zone”

CDC regularly and diligently reviews the structure, content, design, and even color schemes of immunization schedules during public meetings with ACIP. However, it is unclear from the schedule whether vaccines for travel are included. In that note, the schedule indicates that some vaccines (e.g., hepatitis A, hepatitis B, measles, mumps, rubella, meningococcal, and polio) are recommended for international travelers. , schedule notes are separate from that table and are not included. A comprehensive list of all vaccines recommended for travel, omitting vaccines recommended for specific destinations. That information is stored elsewhere on the CDC’s website, creating a maze for travelers, urging them to book vaccines for which coverage may not exist, while travel vaccines are covered. It does not provide clarity of coverage.

The Immunization Schedule landing page has a list of “Adult Immunization Schedule Vaccines” omitting recommended travel vaccines. According to the CDC’s “Travel Vaccines” page, travelers should be up to date on all “routine vaccines” and make sure they mention the measles vaccine. It then directs travelers to a series of pages describing recommended vaccines for specific destinations, and then offers to book the appropriate travel vaccines. Another link on ‘Travel Vaccine Recommendations’ leads to a ‘Traveler Health’ page that highlights the importance of ‘regular vaccinations’ and provides a variety of other traveler health information. increase. Yet another CDC page titled “Vaccines by Disease” has a table listing “Vaccines Recommended for Travel and Certain Specific Groups.” .

Each of the above vaccines was recommended by ACIP to address specific risks to travelers based on a review of available evidence. Ensuring that these recommendations are expressed in the form of a health coverage policy will help facilitate rather than hinder access. In essence, these recommendations are not broad enough to encourage unnecessary use and cost. But to assume that those coverages should be excluded defeats the purpose of recommending vaccines aimed at reducing risk to travelers and preventing the disease from crossing borders.

CDC vaccination schedules should clearly delineate travel vaccine recommendations

There are two simple, legally supported ways for the CDC to clarify that travel vaccine coverage is required under the ACA.

CDC only needs to issue guidance clarifying that travel vaccines are in fact “on schedule” and therefore must be covered under the ACA. This is not unprecedented. In 2019, when I explained that his ACIP recommendations on “sharing clinical decisions” were too vague and confusing for providers and payers, the CDC published a series of FAQs, clarified as follows: Adopted by the CDC and listed on the immunization schedule. Similar guidance from the CDC allows travel lists to be specified as part of the schedule itself and subject to coverage requirements.

CDC will also integrate the above list of recommended travel vaccines into its immunization schedule, creating a table of recommended vaccines, as well as other regularly recommended vaccines, which can trigger an “on schedule” requirement. There is a possibility

CMS may also provide clarity and consistency in travel vaccine coverage

In its recent guidance to Part D sponsors to implement the IRA’s new zero-cost sharing policy on vaccines, CMS noted that ACIP’s recommendations include: of vaccines that are “intended for use in limited populations and settings.”Routine immunization schedule [including] Limited population and situation. This language is readily adopted by CMS and provides important and necessary clarity on travel vaccine coverage that may apply to private health plans and Medicaid under the ACA.

Failure to articulate travel vaccination requirements could jeopardize the expertise and semantics of the “schedule” sense of the millions of U.S. travelers who each year receive potentially life-saving vaccines. It can get in the way. Both CDC and CMS have the mandate to provide this necessary clarity through simple, clear guidance.

author’s note

The authors regularly advise clients, including vaccine manufacturers, on policy, legal, and regulatory issues.

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