Recommended vaccines covered under health law, but coverage may lag

A federal panel of experts has recommended that boys be vaccinated against HPV, noting the virus has been linked to many types of cancer in addition to cervical. With new studies and recommendations emerging and changing all the time, whose word matters, and what do the new recommendations mean for your family’s insurance coverage?

Under the federal health law, insurance companies are required to cover screenings or vaccinations recommended by two different groups–the U.S. Preventive Services Task Force and the Advisory Committee on Immunization Practices, which advises the CDC on vaccines. Once either of those groups issues a final recommendation, insurance providers must start covering it with no cost-sharing, said Susan Pisano, a spokeswoman for America’s Health Insurance Plans. Coverage is not required until the following plan year.

The HPV vaccine recommendation for boys likely will not be finalized for months. At that point, Pisano said the time frame for changing coverage policy varies within the federal requirement.

“It probably makes sense if you are thinking of getting this service for your son to ask your insurer when that coverage might go into effect,” Pisano said. “It’s likely to vary from company to company.”

Some providers change policy relatively quickly; others wait for pre-designated review periods. Some companies, including the Philadelphia area Independence Blue Cross, already cover the HPV vaccine for boys.

The Centers for Medicare and Medicaid Services go through a process that takes six to nine months to change coverage policy for issues relevant to its coverage population, said CMS spokeswoman Lorraine Ryan.

The U.S. Preventive Services Task Force recently reversed a different recommendation–it no longer advises healthy men to get routine PSA blood tests to check for prostate cancer.

Pisano said she has not yet heard of any insurance companies deciding not to cover the test as a result.

“Our sense is that when there is a scaling back or recommendation that suggests risks are outweighing benefits, that medical practice will change, and that when docs and patients are having these discussions, fewer patients will elect to get the test,” Pisano said. “Our sense also is that if an individual clinician and the patient decide it makes sense to go ahead with the test anyway, typically there would be coverage for it.”