There are more unknowns than certainties when it comes to the 2025-2026 COVID-19 vaccine due to recommendation changes from the Food and Drug Administration.
Last year, everyone 6 months and older could get the COVID shot and have it covered by insurance. This year, the FDA has limited access to people 65 and older and younger people with an underlying condition that puts them at high risk of severe disease. Those who aren’t in those groups could get a bill after getting the vaccine, or, in some cases, may be unable to get the shot at all.
It’s not clear how much a COVID shot would cost this fall if insurance doesn’t cover it, but according to Centers for Disease Control and Prevention data for the 2024-2025 shots, one dose for an adult can cost as much as $141.80. There could also be an administration fee on top of that, according to Dr. William Schaffner, a professor of preventive medicine in the Department of Health Policy at Vanderbilt University Medical Center in Nashville, Tennessee.
Shot eligibility could change after Sept. 18 and 19, when the CDC’s Advisory Committee on Immunization Practices (ACIP) meets to go over the FDA’s COVID vaccine recommendations.
“The ACIP meeting next week is going to be important … they have COVID vaccine on the agenda, and I hope they vote clearly as to which populations for which they’re going to make a recommendation for COVID vaccine, which may not please me entirely, but at least we’ll have some clarity,” Schaffner told HuffPost.
“Generally, insurance companies follow the recommendations that are provided by the CDC Advisory Committee on Immunization Practices,” noted Cynthia Leifer, a professor of immunology at the Cornell University College of Veterinary Medicine and contributing writer at Those Nerdy Girls, an online organization that champions accurate health and science information. If the ACIP OKs the COVID vaccine for certain populations, insurance companies will likely follow suit in regards to coverage.
But what does this mean for the people who are potentially not included in the recommendations? Or for those who get their shots now, before the ACIP meeting? We asked experts to break it down.
If you’re in an eligible group, you most likely won’t struggle with insurance covering your shots.
There are currently technological problems with Medicare (which provides health coverage for people over 65) that are causing folks to get charged for the COVID vaccine when they shouldn’t, said Dorit Reiss, an expert in vaccine law and professor of law at the University of California Law at San Francisco.
This is an error, but it adds to the cost confusion around this year’s vaccines.
“Given the tech issues, I’m not sure anyone can be worry-free right now, but Medicare, people over 65, should not have an issue” when it comes to health insurance coverage for the shots, according to Reiss.
Medicare is required to cover vaccines recommended by the ACIP, which, as mentioned, is meeting next week to issue its COVID vaccine guidelines, Reiss explained.
The vaccines are also approved for people under 65 with a health condition that puts them at risk for severe disease, so those individuals also shouldn’t have insurance trouble, “though there’s a question there — because how will they define high risk?” Reiss added.
For example, the CDC does have information on its website regarding what conditions are considered high risk for severe COVID-19, and pregnancy is included in the list. Yet Health and Human Services Secretary Robert F. Kennedy, Jr. has recently said the shot is not recommended for pregnant people.
Exactly what the ACIP will define as high risk is currently unknown, but “people who have clear high risk shouldn’t have an issue. People over 65 shouldn’t have an issue. Everybody else may have an issue,” Reiss said.
Nothing regarding COVID shots is black and white right now, Leifer stressed. Schaffner noted that it’s a messy, “extraordinary environment” right now.
If you are concerned about your insurance coverage ― even if you fall within the approved groups ― it is a good idea to check with your insurance provider about your coverage.
Andriy Onufriyenko via Getty Images
When it comes to health insurance coverage for the COVID vaccine, “people who have clear high risk shouldn’t have an issue. People over 65 shouldn’t have an issue. Everybody else may have an issue,” professor Dorit Reiss said.
If you are outside of the eligibility indicators, it’s much trickier.
If you fall outside of the 65-and-up group and don’t have any underlying conditions, insurance coverage is much dicier, Schaffner said.
There’s mixed information right now. In some states, you may be covered by insurance because of statewide laws. Some insurance plans also may choose cover you, but there is no across-the-board guideline that everyone who isn’t high risk or over 65 can follow.
“We’re … waiting for ACIP recommendations right now,” Reiss said. “Under the Affordable Care Act, private insurers have to cover vaccines recommended by ACIP.”
As we await ACIP recommendations, there are one of two interpretations insurers can take. “One, they can say ‘since the ACIP hasn’t discussed this yet, the recommendation in place is last year’s recommendation, and we’ll follow that and cover.’ Or they can say ‘there’s no recommendations, we don’t have to cover it,’” Reiss explained.
Insurers also can decide to voluntarily cover COVID vaccines, even if ACIP doesn’t recommend them, Reiss added.
Professional organizations such as the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists both went against the FDA’s guidelines and continue to recommend the shot for children and pregnant people.
“There may be some insurance firms that key on the professional society’s recommendations, rather than the ACIP’s, because they’ve lost confidence in the ACIP as it’s currently constituted,” Schaffner said.
But once again, these are all unknowns. More information will come out after the ACIP’s meeting on Sept. 18 and 19.
If you get the shot and lie about your eligibility, you may get a bill.
On social media, some people claim they’re lying about their health conditions and history in order to get the vaccine, whether that’s claiming to be a former smoker or saying they’re physically inactive (both conditions put you in the high-risk category for COVID, according to the CDC’s current documentation).
“What I think is interesting about that, though, is that we’ve seen for years people who didn’t want the vaccine lying about medical conditions to get out of getting the vaccine. Now, we have group of people who want to get the vaccine that are going to try and lie to get the vaccine,” Leifer said. “It’s absolutely crazy. We should just be able to get a vaccine if we want it. And it is important for as many people to get it as possible because it does reduce the amount of virus that is spreading around from person to person, and it protects everyone in the population.”
While it’s important for as many people to get the shot as possible, lying isn’t the best way to go about it if you don’t want to get a surprise medical bill.
“I think if you want the insurance company to cover your vaccine, it’s probably not a good idea to try and go that route and lie to get the vaccine,” Leifer said. “There’s a good chance that you might end up having to pay out of pocket for that.”
Arman Zhenikeyev via Getty Images
Who is eligible for a COVID shot right now depends on many factors right now, which is causing lots of confusion.
Pregnant people and children are in an even trickier situation.
Pregnant people are seeing real obstacles already because the CDC no longer recommends the vaccine for this group, Reiss said.
“And remember that not long ago, FDA itself mentioned that pregnancy is a high-risk condition, so the fact that they’re now making it hard for these people to get the vaccine is then also inconsistent,” Reiss said.
Vaccine access for kids is also sticky. “The problem is even going to be even worse for children. Anyone who wants a child covered is going to be in even more of a mess, partly because of supply, because the FDA now essentially took Pfizer’s under 5 vaccine off the market. Only Moderna can cover that group,” Reiss said.
Insurance coverage for children will be even messier. “ACIP is likely to either not recommend vaccines at all for that group or recommend it very narrowly,” she said.
Some states have their own eligibility rules.
Some states have jumped in to ensure that vaccine costs are covered; this includes states like Massachusetts, which requires insurance companies to pay for COVID shots, Reiss said.
States like Colorado require state-regulated insurers to cover the shot, while other states like New York and Pennsylvania issued orders that ensure folks can get the shot without eligibility restrictions.
The rules vary by state, and it’s unclear how individual state rules will impact insurance coverage.
You can reach out to your local health department or your health insurance company to see if your state has any protections in place regarding COVID shot costs.
If you are afraid of getting a bill for your COVID shot or your kid’s shot, there are a few things you can do.
While Reiss said she can’t promise that you won’t get charged by your insurance for a COVID shot, you can reach out to your insurer to get the most up-to-date information before making your appointment. You can ask your insurer if they’ll cover your shot based on your location, age and health history.
If you call before next week’s ACIP meeting, you may get a muddy answer about vaccine coverage, Schaffner said. You may want to wait a few days after the meeting before calling so insurance companies have time to make coverage decisions, he added.
Be aware “that insurers may decide right now to charge. I know that’s not good news, but the other thing is, remember that states can choose to cover that gap,” Reiss noted.
There is a lot up in the air right now, Leifer said. Different states have different rules, individual pharmacies have varying requirements, and there is even confusion among pharmacists and doctors who are trying to keep up with this ever-changing news.
It’s hard for people who want the vaccine to get a straight answer regarding if they’re eligible, what they need to get the shot and if they’ll have to pay, Leifer added. “What that does is people run out of energy and they just don’t get it, which puts them at risk … for having a serious outcome from the infection,” Leifer said.
These vaccines help prevent hospitalization and death from COVID-19, in addition to conditions like long COVID.
20 Years OfFreeJournalism
Your SupportFuelsOur Mission
Your SupportFuelsOur Mission
For two decades, HuffPost has been fearless, unflinching, and relentless in pursuit of the truth. Support our mission to keep us around for the next 20 — we can’t do this without you.
We remain committed to providing you with the unflinching, fact-based journalism everyone deserves.
Thank you again for your support along the way. We’re truly grateful for readers like you! Your initial support helped get us here and bolstered our newsroom, which kept us strong during uncertain times. Now as we continue, we need your help more than ever. We hope you will join us once again.
We remain committed to providing you with the unflinching, fact-based journalism everyone deserves.
Thank you again for your support along the way. We’re truly grateful for readers like you! Your initial support helped get us here and bolstered our newsroom, which kept us strong during uncertain times. Now as we continue, we need your help more than ever. We hope you will join us once again.
Support HuffPost
Already contributed? Log in to hide these messages.
“The way of doing this this year is just creating more chaos and confusion than ever before,” Leifer said. “I wish it was more straightforward.”
