While exceptions exist, most insurance carriers cover annual flu shots. How and when you can receive these benefits ultimately depends on your provider network, coverage details, and location.
For example, almost all employer and private health plans cover flu shots as preventative services. According to the Affordable Care Act (ACA) mandate, these companies cannot impose copay or deductible fees for eligible vaccinations.
Likewise, Medicare recipients would pay nothing for a seasonal flu shot from an approved healthcare provider, medical facility, or pharmacy. Contrarily, while most Medicaid programs still provide members with complimentary influenza vaccines, some states may restrict coverage or impose out-of-pocket copayments or coinsurance.
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Why Flu Shots Matter
Influenza often only results in moderate illness and time off school or work, but it can also lead to hospitalization or death. The Centers for Disease Control and Prevention (CDC) recommends an annual vaccination to reduce these risks and other complications. Standard quadrivalent flu shots cause antibodies to develop in our immune systems and protect against four specific viruses: influenza A(H1N1), influenza A(H3N2), and two forms of influenza B.
Vaccinated patients have a significantly decreased probability of contracting the flu. Even those who become sick will experience less severe symptoms and likely avoid hospitalization. Notably, getting vaccinated also helps prevent the virus from spreading to vulnerable members of your community, such as infants, older people, and immunocompromised individuals.
How Different Insurance Types Cover Flu Shots
Your flu shot coverage will depend on your policy details and whether you have ACA-compliant health insurance, a grandfathered health plan, Medicare, or Medicaid.
Private and Employer-Sponsored Health Insurance
When the Affordable Care Act triggered nationwide healthcare reform in 2010, it set up the online Health Insurance Marketplace to sell subsidized and regulated health insurance policies to individual citizens and their families. Likewise, it began requiring larger companies to provide their employees with affordable health coverage. Whether you have standalone or employer-sponsored benefits, all ACA-compliant policies must cover 100% of a seasonal flu shot as preventative care.
Marketplace and employer health plans come in many variations, each with different provider networks and restrictions. People on HMO plans can typically only receive flu shots from in-network doctors or affiliated hospitals and pharmacies. Contrarily, PPOs allow patients to receive out-of-network vaccines for no additional cost.
Grandfathered Health Plans
If an insurance policy existed before the ACA, it can still operate as a grandfathered health plan. To maintain grandfathered status, the overseeing insurance carrier must refrain from making significant coverage updates or policy changes. If your grandfathered plan provided vaccine benefits before 2010, it still would today. The same restrictions would apply if it did not previously cover flu shots.
As with ACA-compliant policies, where you can receive covered flu shots depends on your provider network and restrictions. If you have a PPO, you will likely have affordable access to vaccines from any conveniently located pharmacy, grocery store, or doctor’s office. If you have an HMO, you must visit your PCP or another in-network facility.
Medicare
Medicare is a federally subsidized health insurance program for adults over 65 and younger people with specific disabilities. Because older individuals pose a higher risk of developing severe complications from the flu, Part B covers 100% of annual vaccinations and waives its usual deductible charge. Members must visit a healthcare provider accepting Medicare assignments to ensure these benefits.
Where you can receive a Medicare-covered flu shot depends on whether you have Original Medicare or Medicare Advantage. Most doctors, hospitals, and pharmacies across the country accept Original Medicare. Contrarily, Medicare Advantage incorporates traditional plan-based provider networks. People with Medicare Advantage HMOs may only have covered access to vaccines received from specified doctors or pharmacists.
Medicaid
Medicaid is a federally funded, state-operated health insurance program for individuals and families below a specific income threshold. Though Medicaid benefits vary from state to state, all policies must meet baseline federal guidelines. In most cases, eligible individuals can enroll in Medicaid and access coverage for no money out of pocket.
According to the ACA mandate, all compliant health insurance plans must cover preventative care and eligible vaccines. Therefore, almost all Medicaid programs cover 100% of seasonal flu shots. In rare cases, certain states may charge members a marginal copayment for the service. To ensure coverage, all beneficiaries must secure their vaccination from a healthcare provider within state boundaries who actively accepts Medicaid.
How Much Do Flu Shots Cost?
Without insurance, a standard quadrivalent flu shot from your PCP could range from $15 to $30. On average, high-dose flu shots for people over 65 cost around $75.
Fees tend to skew higher if you receive the vaccine from an urgent care center and can cost even more if you go to a corporate pharmacy like Walgreens or Walmart. For example, urgent care centers charge an average of $32 for a quadrivalent flu vaccine. Getting the same shot at CVS could cost closer to $42.
Who Should Get a Flu Shot?
The CDC recommends that nearly everyone over 6 months old receive an annual flu shot. Relevant populations include:
- Individuals over 65 who require a high-dose injection
- Adults above 18 eligible for recombinant flu vaccines
- Young children who require standard-dose inactivated vaccinations
- Pregnant women with certain chronic conditions
Contrarily, the CDC also states that the following groups should NOT get vaccinated:
- Children younger than 6 months old
- People with severe allergies to vaccine ingredients like gelatin or antibiotics
- People who have already experienced a severe or life-threatening reaction from a previous flu shot
Additionally, people with Guillain-Barre Syndrome or others already experiencing flu symptoms may want to consult their doctor before scheduling a vaccination.
Alternative Ways to Pay for a Flu Shot
If you do not have health insurance or cannot secure flu shot coverage through your current provider, consider the following alternatives:
- The Vaccines for Children (VFC) program: This federally funded program provides free vaccinations to children under 19 who lack adequate insurance coverage or meet other demographic criteria.
- Local health centers: These institutions receive funding from the Human Resources and Services Administration (HRSA) to provide vaccines and other medical services to millions of Americans, regardless of their ability to pay.
- State immunization programs: Each state’s health department offers varying low-cost vaccines considered integral to protecting local health interests.
- Prescription Savings Clubs: Several pharmacies offer these memberships to individuals regardless of insurance status. By accumulating cash purchases, customers can activate rewards like discounted seasonal vaccines.
Does Insurance Cover the High-Dose Flu Vaccine?
High-dose vaccinations – or “senior flu shots” – incorporate 3-4 times more antigens than traditional vaccines, triggering a more robust immune response in older adults. Because only individuals over 65 typically require these specific injections, they regularly fall under Medicare’s jurisdiction. Medicare Part B and Medicare Advantage cover 100% of an annual high-dose shot as preventative care and waive any unmet deductible fees.
Putting It Together
The CDC recommends that most American adults and children secure a vaccination. These shots significantly reduce your likelihood of contracting and spreading the virus throughout your community. Even if you fall ill, getting vaccinated in advance should minimize the severity of your symptoms.
Without a vaccine, influenza can occasionally lead to hospitalization or even death. Luckily, most insurance policies cover flu shots as preventative care. If you do not have insurance, try accessing free or discounted services through your state immunization program, local health centers, or Prescription Savings Clubs.