Workplace insurance stymied by shifting vax rules

• Until there's more clarity, or until an independent medical authority sets generally accepted rules, many plans are quietly staying the course while acknowledging they can't tell workers whether they'll be on the hook in the future for vaccines that sometimes cost hundreds of dollars.

What we're hearing: The uncertainty and confusion is hitting hard at health plans that cover about two-thirds of American workers.

• Employers who self-insure collect premiums from workers and pay claims themselves, often with the help of a health insurer or pharmacy benefit manager to oversee benefits.
• For vaccines, these plans historically relied on federal health agencies and their outside vaccine advisers for guidance on coverage.
• But that was thrown into flux after the Food and Drug Administration withdrew emergency use rules for COVID vaccines like Novavax's Nuvaxovid and tightened eligibility for other COVID shots to older Americans or those with underlying conditions.
• The situation became even murkier as medical professionals called into question recommendations Kennedy's vaccine advisers made at a two-day meeting this month.

What they're saying: "It is becoming impossible to determine what the FDA has approved, what the [Centers for Disease Control and Prevention] has approved, and whether that will be changing," Kathryn Bakich, senior vice president for health compliance and attorney at Segal told BenefitsPro.

While the employers seek clarity, states are moving on their own to set rules for who can access which shots.

• Blue states are forming public health alliances in response to what they say is the politicization of public health agencies.
• California and Massachusetts have also passed laws to require insurers to cover COVID-19 vaccines, and others have taken steps to ensure the shots are available to anyone who wants them.
• On the other side, states including Florida and Texas are emphasizing personal choice by ending vaccine mandates and otherwise making it easier to opt out of public health measures.

Employers with operations across the country have to face the reality that what works in California may not in red states, said Shawn Gremminger, CEO of the National Alliance of Healthcare Purchaser Coalitions.

Picture this: During recent employer focus groups, KFF officials got an earful from companies that operate across state lines about the confusion they're facing, Cynthia Cox, vice president and director of the program on the Affordable Care Act at KFF, told Axios.

• "It's like 'Who do you trust? Which group's recommendations do you base your coverage on?'" Cox said.
• Vaccine access is especially thorny to navigate, because the Trump administration is raising questions about the underlying science, including the safety and efficacy of mRNA vaccines, Cox said.
• It's left employers and insurers looking to medical professionals to create coverage standards, she said.

• "It's a weird place to be and challenging for employers," Gremminger said. "If you're a nationwide employer, you're like, 'Do I need to have a different vaccine coverage schedule in terms of what I'm willing to cover and cost share between my employees in Massachusetts and my employees in Texas, my employees in Florida and my employees in California?'"

Between the lines: Before COVID, vaccines were the easiest part of employer health plans to deal with, Gremminger said. They even put out vaccine education and hosted worksite vaccine drives.

• "Vaccines don't cost that much money. In general, we know that they work. There was a very kind of clear guidance on who should get vaccinated. It was reset and forget every year. It was like: 'OK, we follow the vaccine schedule,'" he said.
• Then, the pandemic hit, forcing employers to confront vaccine politics and back-to-work expectations.
• "I think a lot of employers felt really burned by that experience. People started having very strong opinions on this issue," Gremminger said. "What they've tended to do is say 'Look, we're just going to keep doing what we've always done. We're going to cover all the vaccines. We're going to tie it to the ACIP vaccine schedule."

What to watch: Groups like the Vaccine Integrity Project, led by the the University of Minnesota, has sought to serve as a convener of medical societies and infectious disease experts in filling the space once reserved for federal vaccine advisers.

• Medical groups like the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have been vocal in offering recommendations.

What's next: The big insurance lobby AHIP has said its members will continue to cover vaccines that were approved as of Sept. 1 during the 2026 plan year.

• But it's still anyone's guess who insurers and employers will turn for future guidance.