What employers need to know about federal vaccine policy changes 

As recent headlines make clear, federal vaccine policy is in a state of flux. There are a lot of moving pieces to process, including the Food and Drug Administration’s limited approval of this season’s COVID-19 vaccine, changes to long-standing recommendations by the Advisory Committee on Immunization Practices and the strong response by AHIP and other groups. In this post, we’ll first break down the FDA’s actions and ACIP’s recommendations for COVID and MMRV vaccines and then explain what they mean for employer-sponsored health plans, employees and public health.

COVID vaccinations

ACIP, which advises the CDC on vaccines, recently voted to change its recommendations for who should get the COVID vaccine. ACIP recommendations are important because they dictate what group health plans must cover without cost-sharing. Based on the previous recommendation, plans currently cover routine COVID vaccines without cost-sharing for most children ages 6 months to 17 years and adults ages 18 and older. ACIP’s new recommendation is more narrow: For all individuals ages 6 months and older, vaccines are recommended based on shared clinical decision-making.

The distinction between a “routine” recommendation and a “shared clinical decision-making” recommendation is the default decision to vaccinate. For routine recommendations, the default decision is to vaccinate unless it is contraindicated. For shared clinical decision-making recommendations, there is no default. Instead, the decision to vaccinate is individualized and may be informed by scientific evidence, the individual’s demographics and risk factors and a healthcare provider’s clinical discretion. A healthcare provider is anyone who administers vaccines, including a physician, physician assistant, nurse practitioner, registered nurse or a pharmacist.

Technically, group health plans only have to provide no-cost coverage of “immunizations for routine use,” which the ACA defines as any listed on the CDC immunization schedules. Assuming the CDC adopts ACIP’s September shared clinical decision-making recommendation, plans must continue no-cost coverage as long as the COVID vaccine remains on the schedule. Beginning in the plan year following CDC’s adoption, no-cost-sharing coverage would also be required for a provider consultation related to whether a plan member should get the shot.

The FDA’s recent action also serves to limit the availability of COVID shots for healthy children and adults. Where previous COVID shots were approved for anyone 6 months or older regardless of risk factors, the FDA limited approval of this fall/winter season’s vaccine to those over 65 and younger individuals with at least one underlying condition that puts them at high risk for severe infections (like asthma or obesity). However, providers may still administer the vaccine to individuals under age 65 without underlying conditions, consistent with “off-label” use and ACIP’s shared clinical decision-making recommendation.

Measles, mumps, rubella and varicella

The combined Measles, Mumps and Rubella vaccine has been a rite of passage for children in the US since 1971. The chickenpox (varicella) vaccine was first available in 1995, and in 2005 a combined Measles, Mumps, Rubella and Varicella vaccine was created. Historically, ACIP has recommended a 2-dose vaccine schedule for children ages 12 months-12 years, with the first dose administered at age 12-15 months and the second dose at age 4-6 years. In 2009, ACIP recommended the first dose of these vaccines be administered as two injections (MMR and V) unless the caregiver expressed a preference for the combined MMRV, the combined MMRV was preferred for the second dose.

This recommendation was changed slightly at ACIP’s most recent meeting, when the committee approved a recommendation for the 2-dose vaccine schedule using separate injections (MMR and V) for the first dose in children under the age of 4 years — in other words, removing the combined MMRV option for the first dose for this age group. The combined injection remains an option for the second dose. This change to the vaccine schedule — if adopted by the CDC — may impact the federal Vaccines for Children Program, which routinely offers the combined MMRV injection to improve vaccination rates, but will have little practical impact on employer group plans and their members. Nationally, the combined MMRV injection accounts for only 15% of first dose vaccination among children ages 19-35 months.

Employer considerations

With federal recommendations changing and vaccination rates declining, employers can play a pivotal role in creating awareness of — and access to — vaccines covered under the group health plan. Public health experts still consider COVID to be a threat, especially for young children and adults 65 years and older, as demonstrated by CDC data. And so far in 2025, at least 40 measles outbreaks have been reported to the CDC, the most since the disease was declared eliminated in the US in 2000. In all cases, prevention and treatment are key to keeping communities healthy and safe from communicable diseases.

We encourage employers to consider the following:

• Plan coverage of vaccines without cost-sharing will continue. Group health plans must continue coverage as is through the end of the plan year. Employers and carriers can implement changes in accordance with revised ACIP recommendations for the plan year following the CDC’s adoption. Thus far, any changes for the next plan year are likely to be limited since COVID, MMR and varicella vaccines must still be covered at no-cost to plan members (assuming CDC’s adoption of ACIP’s recommendations). Only if COVID were to be dropped entirely from the immunization schedule, would plans no longer be required to provide no-cost coverage for the shot and the provider consultation.

• Access to COVID vaccines may be more challenging than before. The FDA’s limited approval of COVID shots for the fall/winter season, along with the change to ACIP’s recommendation from routine to individualized, may make the shot harder to access. Ease of access at pharmacies depends in part on where one lives, as not all states allow pharmacists to administer shots that aren’t routine without a prescription. For example, in some states the pharmacist may require a prescription to administer the shot to a child and confirmation of an underlying condition for adults, in others, a prescription may be required for anyone seeking the shot. The confusion will be most acute for employees of multi-state employers if the health plan isn’t able to provide clarity around coverage and access. In addition, plan members who look to their providers for advice may not be able to get the shot from them. Many physician offices aren’t expected to stock the shot because in prior seasons only 8% of adults went to the doctor — as opposed to the pharmacy — to get it. These challenges may deter plan members who sought out the shot in the past, and as a result, employers may see fewer employees overall getting vaccinated this season.

• Claim administration for COVID shots may be more challenging. While ACIP’s shared clinical decision-making recommendation is for the next plan year, confusion may result this year. If plan members seek advice from providers about the shot, will those encounters be coded as preventive and covered at no cost to the plan member? Next year, assuming COVID remains on the CDC’s immunization schedule, these encounters must be covered at no cost. Consultation with carriers, third-party administrators and pharmacy benefit managers is recommended to understand the claim administration process and medical coding requirements to ensure these claims are properly adjudicated as preventive this plan year and next.

• Employees may look to you for advice. Some employers may want to consider what, if anything, to communicate to employees or plan members about the recent federal policy changes around vaccines. It’s important to confirm plan coverage details and any changes expected for the next plan year with your health plans and PBMs before communicating how members can get vaccinated without cost-sharing. You might also review company leave policies and communicate relevant information about taking time away from work to get vaccinated. Consider including information from vendor partners or trusted organizations about vaccine safety and efficacy (see for example, resources from the Health Action Alliance).

What’s next for vaccine policy?

This is unlikely to be the last time employers will need to grapple with changes to long-standing federal vaccine policy. In future meetings, ACIP will reconsider other shots on the childhood immunization schedule. Yet days before ACIP’s last meeting, AHIP, the national trade association representing the health insurance industry, pledged to continue no-cost-sharing coverage of immunizations that were recommended by ACIP as of September 1, 2025 (prior to the recent revisions) through the end of 2026. Separately, public health experts have discussed forming an independent vaccine board, and medical associations like the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists have published their own vaccine recommendations. The AARP has offered recommendations for individuals over age 50.

While ACA-mandated employer group health plan coverage requirements will be dictated by CDC’s immunization schedules (informed by ACIP), self-funded employers may be pressured to expand coverage based on competing schedules while fully insured plans may find states forging their own path or in concert with neighboring states. During these changing times, one thing is certain — the ROI on preventive vaccination for most employers makes it an issue worthy of attention.