Journal of Community Health

, Volume 37, Issue 6, pp 1164–1167 | Cite as

Underinsurance for Recently Recommended Vaccines in Private Health Plans

  • Dianne C. Singer
  • Matthew M. Davis
  • Achamyeleh Gebremariam
  • Sarah J. Clark
Original Paper

Abstract

Underinsurance for vaccines presents financial barriers to vaccination. Preventive services coverage is of interest in national healthcare reform. To assess vaccine benefits coverage in private health plans. Private health insurance carriers were surveyed December 2008–June 2009 on policies regarding vaccine coverage in fully insured plans. Carriers were identified as multi-state, state-specific Blue Cross or local-independent carriers. Plan types included HMO, PPO, POS and ‘other.’ Full benefits coverage was defined as having benefits without a copay or coinsurance for a recommended vaccine. Analyses were conducted to examine associations between carrier type, plan type, and full benefits coverage. Fifty-one carriers (response rate = 56 %) provided data for 78 unique plans, reflecting over 47 million private plan enrollees. Full benefits coverage was highest for combined tetanus/diphtheria/acellular pertussis (74 %) and lower for pneumococcal conjugate (72 %), rotavirus (72 %), human papillomavirus (71 %), hepatitis A (68 %), meningococcal conjugate (67 %), inactivated influenza (67 %), live attenuated influenza (63 %) and zoster (57 %) vaccines. Compared with plans offered by state-specific Blue Cross carriers, significantly higher proportions of multi-state carriers and local independent carriers had plans with full benefits coverage for vaccines (p < 0.05). Compared with PPO and “other” plans, significantly higher proportions of HMO and POS plans had full benefits coverage for vaccines (p < 0.05). In this national study, levels of underinsurance for immunization leave room for improvement. State-specific Blue Cross plans and indemnity or high-deductible plans are least likely to offer full coverage for recently recommended vaccines, and may face changes with incorporation of “essential health benefits” requirements.

Keywords

Immunization Vaccines Health plans Underinsurance Preventive services 

Background

Underinsurance for vaccines occurs when private insurance plans do not include benefits for all vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) [1, 2]. Recent strong upward trends in vaccine prices present barriers to vaccine purchase for individuals and public programs (e.g., the federal Vaccines for Children program) alike [3, 4].

Underinsured individuals are less likely than peers with full benefits coverage to receive recommended vaccines and thereby fail to benefit from the protection that vaccines afford [1, 2]. Although underinsurance for vaccines has been examined for children at individual and plan levels [5, 6], there have been no national estimates of underinsurance for children and adults for the multitude of vaccines newly recommended in the last decade [7, 8].

Coverage in private insurance plans for preventive services has drawn increasing attention because of provisions in the 2010 healthcare reform law, the Patient Protection and Affordable Care Act (ACA) [9]. Under the ACA, new health plans made available through state-level exchanges must cover a set of services known as “essential health benefits”; preventive services are specifically identified as one of 10 categories of benefits to be included in the plans. A committee convened by the Institute of Medicine in 2011 established guidelines and criteria for identifying essential health benefits, but stopped short of identifying the benefits themselves [10]. Private health plans that wish to participate in the exchange as an insurer have a strong interest in understanding prevailing norms in coverage of preventive services, because such norms may guide inclusion of benefits in essential packages.

We examined a recent national sample of private health insurance plans in the United States for which benefits data were available, to determine the frequency with which benefits for recommended childhood, adolescent and adult vaccines are included.

Methods

Study Sample

We contacted insurance commissioners in all states and requested information about the three insurance carriers with the highest enrollment. All commissioners responded. The original sample included 3 carriers in 47 states (2 states did not collect carrier data; 1 state collected only small employer data). Of 141 candidate carriers, 2 were ineligible (1 carrier had only Medicare plans; 1 did not offer health plans), leaving a contact sample of 139 carriers.

Carriers that operated in >1 state were classified as “multi-state” carriers. Otherwise, carriers were originally classified as “state-specific Blue Cross” carriers or “local independent” carriers. State-specific Blue Cross carriers that operated in multiple states were reclassified as multi-state carriers.

Data Collection and Survey Design

Using a standardized form, carriers were asked to provide information on prevailing coverage policies for immunization coverage for the following 9 vaccines and indicated age groups, recommended after January 2000:
  • children: pneumococcal conjugate (PCV), rotavirus (rota), hepatitis A (HepA), inativated influenza (TIV), live attenuated influenza (LAIV)

  • adolescents: combined tetanus/diphtheria/acellular pertussis (Tdap), human papillomavirus (HPV), meningococcal conjugate (MCV), TIV, LAIV

  • adults: herpes zoster (zost), Tdap, HPV, MCV, TIV, LAIV.

Carriers responded to survey questions regarding 2009 for their most heavily enrolled fully insured plans. Some carriers also provided data regarding their second and third most heavily enrolled plans. Data collection was multimodal (electronic, telephone, facsimile or mail), depending on preference of respondent.

Data Analysis

For each vaccine, we calculated the proportion of plans with full benefits coverage overall, as well as by carrier type and by plan type. We used Fisher’s exact test to ascertain the statistical significance of bivariate analyses between benefits coverage and carrier and plan types. The study was approved by the University of Michigan Institutional Review Board.

Results

Sample Characteristics

Of 139 carriers in the original contact sample, 53 (38 %) were multi-state carriers, 44 (32 %) were state-specific Blue Cross carriers, and 42 (30 %) were local independent carriers. The 53 multi-state carriers represented 5 unique major carriers that operate similar plans across multiple state markets. In contrast, each state-specific Blue Cross and local independent carrier represented a unique carrier.

Therefore, the final contact sample included 91 unique insurance carriers. Of these, 51 responded (response rate = 56 %). Response differed by carrier type: 100 % (n = 5) for multi-state, 68 % (n = 30) for state-specific Blue Cross, and 37 % (n = 16) for local independent.

From these 51 carriers, vaccine benefits data were collected for 78 fully insured plans (13 multi-state, 40 state-specific Blue Cross, 25 local independent). These plans were categorized by the carriers into 4 mutually exclusive plan types: 43 preferred provider organization (PPO), 17 health maintenance organization (HMO), 9 point of service (POS) and 8 other (indemnity or high deductible health plan). One plan was not categorized by the carrier.

Enrollment (reported for 65 of 78 plans) was estimated by carriers at 47, 234, 235 members. Distribution of members across carriers was 72 % multi-state, 23 % state-specific Blue Cross and 5 % local independent. The distribution of members by plan type was 36 % HMO, 35 % POS, 27 % PPO, and 2 % other.

Benefits Coverage for Recently Recommended Vaccines

Overall, full benefits coverage of individual vaccines ranged from 74 % (Tdap) to 57 % (zost). Compared with plans offered by state-specific Blue Cross carriers, significantly greater proportions of multi-state and local independent plans had full coverage for vaccines (Table 1). Compared with PPO and ‘other’ plans, greater proportions of HMO and POS plans had full coverage for vaccines (Table 2).
Table 1

Proportion of plans with full benefits coverage for vaccines, by carrier type

 

Total N = 78 (%)

Multi-state carriers N = 13 (%)

State-specific blue cross carriers N = 40 (%)

Local independent carriers N = 25 (%)

Tdap

74

92

60

88

PCV

72

92

55

88

Rota

72

92

54

88

HPV

71

92

53

88

Hep A

68

92

50

86

MCV

67

69

53

87

TIV

67

92

48

84

LAIV

63

92

42

80

Zost

57

46

42

84

Proportions significantly different (p < 0.05) for all vaccines across carrier type, except herpes zoster (NS)

Tdap combined tetanus/diphtheria/acellular pertussis, PCV pneumococcal conjugate, Rota rotavirus, HPV human papillomavirus, HepA Hepatitis A, MCV meningococcal conjugate, TIV trivalent inactivated influenza, LAIV live attenuated influenza, Zost herpes zoster

Table 2

Proportion of plans with full benefits coverage for vaccines, by plan type

 

Total N = 77 (%)a

HMO N = 17 (%)

PPO N = 43 (%)

POS N = 8 (%)

Other N = 9 (%)

Tdap

74

94

72

89

25

PCV

72

94

68

89

25

Rota

72

94

68

89

14

HPV

71

94

66

89

25

HepA

68

94

61

89

25

MCV

66

88

63

78

25

TIV

67

94

61

78

25

LAIV

64

88

59

78

25

Zost

57

76

54

67

25

HMO health maintenance organization, PPO preferred provider organization, POS point-of-service, Tdap combined tetanus/diphtheria/acellular pertussis, PCV pneumococcal conjugate, Rota rotavirus, HPV human papillomavirus, HepA Hepatitis A, MCV meningococcal conjugate, TIV trivalent inactivated influenza, LAIV live attenuated influenza, Zost herpes zoster

a1 plan did not specify plan type

Discussion

This study provides unprecedented information about benefits coverage for ACIP-recommended vaccines in fully insured private health plans. The key finding is that proportions of plans with full benefits coverage vary across recommended vaccines from the mid-60s to mid-70s, and the coverage for herpes zoster vaccine is <60 %. Such coverage is consistent with recent national measures of underinsurance at the child level [5] and in a smaller study of 15 carriers [6]. Overall, these proportions are evidence of ample room for improvement in vaccine benefits coverage: members in about 1 of every 3 plans are underinsured.

Another major finding of this study is that the benefits coverage patterns appear strongly related to carrier type and financial structure. State-specific Blue Cross plans—accounting for one-quarter of enrollees in this national sample—have less comprehensive vaccine benefits coverage than multistate plans and independent local plans. Most of these plans are members of the national Blue Cross and Blue Shield association, which may prove to be a communication opportunity to promote improved vaccine benefits coverage in these plans.

Our finding that many indemnity-style and high-deductible plans do not include benefits for recently recommended vaccines is conceptually consistent with the limited benefits approach of these plan designs, which provide coverage for a small fraction of enrollees. Low levels of benefits for vaccines in PPO plans are more surprising and more concerning, given much higher levels of enrollment in such plans. This finding merits further investigation and discussion with plan benefits decision-makers. Importantly, over 70 % of enrollees in this sample were covered in HMO and POS plans, which have more comprehensive vaccine benefits coverage.

The national scope of this study benefited from the cooperation of state insurance commissioners and participation of dozens of private insurance carriers around the country. Fully insured plans provide coverage for an estimated 80 million Americans—about one-half of all Americans who have employer-sponsored health insurance [1]. The fully insured plans in this study cover over 47 million enrollees; as such, these findings reflect coverage for more than half of all fully insured Americans in 2009.

Nevertheless, the chief limitation of this study is that only employer-sponsored plans were included in the study. Plans offered for individual purchase may have very different coverage parameters, although their enrollment is less than 10 % of employer-sponsored plans. Self-insured plans, typically offered by large employers, were not included in this study because benefits information in such plans is proprietary. Another limitation is that we did not verify the benefits coverage reported for vaccines in the sampled plans. Although there may have been some social desirability bias for plans to report benefits coverage when none existed, our sense was that carriers were forthcoming with benefits information. An additional potential limitation is that the data collection for this study was conducted about 2 plan cycles ago. Our experience in similar analyses in the past, however, is that plan benefits for preventive services are fairly stable over time. Therefore, we believe that our findings likely closely approximate the status of benefits in 2011.

In conclusion, our unique findings advance current understanding of the challenge of underinsurance for vaccines. To the extent that underinsurance creates a financial barrier to vaccination, state or federal insurance mandates to include benefits for ACIP-recommended vaccines in private health plans will likely facilitate higher vaccination rates. Furthermore, if provisions of the ACA lead authorities to include all ACIP-universally-recommended vaccines in essential health benefits packages for exchange-based health plans, then a large minority of health plans may need to adjust their coverage for prophylactic vaccines.

Notes

Acknowledgments

This study was supported by Cooperative Agreement Number U48 DP000055 from the Centers for Disease Control and Prevention. The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Conflict of interest

The authors have no conflicts of interest to report.

References

  1. 1.
    Institute of Medicine. (2003). Financing vaccines in the 21st century: Assuring access and availability. Washington, DC: National Academies Press.Google Scholar
  2. 2.
    Orenstein, W. A., Douglas, R. G., Rodewald, L. E., & Hinman, A. R. (2005). Immunizations in the United States: Success, structure, and stress. Health Affairs (Millwood), 24, 599–610.CrossRefGoogle Scholar
  3. 3.
    Davis, M. M., Zimmerman, J. L., Wheeler, J. R. C., & Freed, G. L. (2002). The costs of childhood vaccine purchase in the public sector: Past trends, future expectations. American Journal of Public Health, 92, 1982–1987.PubMedCrossRefGoogle Scholar
  4. 4.
    Davis, M. M. (2010). Price as a double-edged sword in the golden era of vaccines. Human Vaccines, 6, 689–693.CrossRefGoogle Scholar
  5. 5.
    Smith, P. J., Molinari, N.-A., & Rodewald, L. E. (2009). Underinsurance and pediatric immunization delivery in the United States. Pediatrics, 124, S507–S514.PubMedCrossRefGoogle Scholar
  6. 6.
    Shen, A. K., Hunsaker, J., Gazmararian, J. A., Lindley, M. C., & Birkhead, G. S. (2009). Role of health insurance in financing vaccinations for children and adolescents in the United States. Pediatrics, 124, S522–S531.PubMedCrossRefGoogle Scholar
  7. 7.
    Centers for Disease Control and Prevention. (2010). Recommended adult immunization schedule—United States. MMWR. Morbidity and Mortality Weekly Report, 59, 1–4.Google Scholar
  8. 8.
    Centers for Disease Control and Prevention. (2010). Recommended immunization schedules for persons aged 0 through 18 years—United States, 2010. MMWR. Morbidity and Mortality Weekly Report, 58, 1–4.Google Scholar
  9. 9.
    Patient Protection and Affordable Care Act. (2010). Public Law 111–148. Text available at http://democrats.senate.gov/reform/patient-protection-affordable-care-act-as-passed.pdf. Accessed April 4, 2011.
  10. 10.
    Institute of Medicine. (2011). Essential health benefits—balancing coverage and cost. Available at http://www.iom.edu/~/media/Files/Report%20Files/2011/Essential-Health-Benefits-Balancing-Coverage-and-Cost/essentialhealthbenefitsreportbrief4.pdf. Accessed November 15, 2011.

Copyright information

© Springer Science+Business Media, LLC 2012

Authors and Affiliations

  • Dianne C. Singer
    • 1
  • Matthew M. Davis
    • 1
    • 2
    • 3
  • Achamyeleh Gebremariam
    • 1
  • Sarah J. Clark
    • 1
  1. 1.Division of General Pediatrics, Child Health Evaluation and Research (CHEAR) UnitUniversity of MichiganAnn ArborUSA
  2. 2.Division of General MedicineUniversity of MichiganAnn ArborMichigan
  3. 3.Gerald R. Ford School of Public PolicyUniversity of MichiganAnn ArborMichigan

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