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In the early days of the West Texas measles outbreak, Thang Nguyen eyed the rising number of cases and worried. His 4-year-old son was at risk because he had received only the first of the vaccine’s two doses.
So, in mid-March, he took his family to a primary care clinic at the University of Texas Medical Branch in Galveston.
By the end of the visit, his son, Anh Hoang, had received one shot protecting against four illnesses — measles, mumps, rubella, and chickenpox. He also received a second shot against tetanus, diphtheria, and whooping cough, as well as a flu shot. His twin daughters, who had already had their measles vaccinations, got other immunizations.
Nguyen, who is a UTMB postdoctoral fellow in public health and infectious disease, said he asked clinic staff whether his family’s insurance would cover the checkups and immunizations. He said he was assured that it would.
Then the bills came.
The medical procedure
The first measles vaccine was licensed in 1963 and became part of the combination measles, mumps, and rubella, or MMR, vaccine in 1971. Today the vaccine against chickenpox, or varicella, is sometimes combined into what is known as the MMRV vaccine.
A first dose of the measles vaccine is usually given between 12 and 15 months, with a second between ages 4 and 6. Experts may recommend vaccinating children at younger ages during an outbreak — like the ongoing U.S. measles outbreak, which has led to more than 1,200 cases, 750 of them in Texas. According to the Centers for Disease Control and Prevention, 95% of the cases have occurred in unvaccinated people or those whose vaccine status is unknown.
Recommendations affecting administration and insurance coverage are made by the Advisory Committee on Immunization Practices. In mid-June, Health and Human Services Secretary Robert F. Kennedy Jr. replaced the committee, adding vaccine skeptics. The new panel, which met last week, is expected to scrutinize past recommendations, including for the MMR vaccine.
The final bill
UTMB billed $2,532 for the boy’s office visit and three shots. The MMRV shot alone was billed at $1,422, plus $161 for administering it.
The billing problem: Coverage gaps and provider ‘errors’
There are guardrails in the U.S. health system intended to prevent recommended vaccines from being prohibitively expensive. They did not help the Nguyen family.
Their health plan, purchased from insurance broker TaiAn for Nguyen’s wife and children and administered by the International Medical Group, does not cover immunizations. And, initially, the family was not offered assistance under the Vaccines for Children Program, a federally funded effort, created after a measles outbreak more than 30 years ago, that provides free immunizations for uninsured and underinsured children.
So the family was exposed to the sticker shock of U.S. medical care without insurance, with providers setting prices. In this case, UTMB’s price for the child’s MMRV shot was about $1,400, more than five times what the CDC says it costs in the private sector.
Nguyen was surprised when their insurer did not pay anything, leaving bills for his three children’s checkups that, combined, were close to $5,000.
He said the family’s income, from his job in UTMB’s labs, is less than $57,000 a year. Nguyen’s job provides him health insurance, but he balked at the $615 a month it would cost to cover his family, too, and instead purchased the one-year policy from TaiAn, which totaled $1,841. The policy covers certain types of office visits, emergency room care, hospitalization, and chemotherapy, but not immunizations or checkups.
Nguyen and his wife, who are from Vietnam, are living in the country on temporary visas while he completes his studies. In Vietnam, Nguyen said, the total cost of the preventive care his family received at the clinic would probably be no more than $300.
He was concerned about the high prices set by the clinic for the vaccines, particularly during a measles outbreak.
“It’s insane,” he said.
Carly Kessler, a spokesperson for International Medical Group, confirmed in an email to KFF Health News that the family’s plan does not cover preventive care, including immunizations.
After UTMB was contacted by KFF Health News, its vice president of clinical contracting strategies, Kent Pickering, looked into the matter. “This situation should not have happened” but did so because of “a series of errors,” he said in an interview.
Most insurance offered in the U.S. must cover, without copays, a variety of preventive care services — including the measles vaccine — under rules in the Affordable Care Act. But some plans are exempt from those rules, including short-term plans or travel insurance. International students on temporary visas do not have to buy an ACA-compliant plan during their first five years in the country.
But what about the cost of the vaccines?
Hospitals and other providers may set their own prices for services, creating price lists called chargemasters. Insurers negotiate discounts for services they agree to cover. People with no insurance coverage are generally on the hook for the full amount.
“One of the most frustrating parts of our health care system is that people who don’t have health insurance coverage have to pay far more than even a health insurance company would pay,” said Stacie Dusetzina, a professor of health policy at Vanderbilt University Medical Center.
While prices can vary, the CDC’s Vaccines for Children Program price list shows the MMRV vaccine — also known by the brand name ProQuad — costs about $278 in the private sector. Consumer prices for ProQuad at Galveston-area pharmacies range from about $285 to $326, according to the prescription cost-tracking website GoodRx.
UTMB’s Pickering told KFF Health News that, initially, the Nguyen family’s insurance was entered incorrectly by the clinic staff, so they did not pick up that his plan didn’t cover vaccines. If they had, UTMB likely would have checked whether the Texas Vaccines for Children Program would cover the cost of the shots, charging only the program’s small administration fee.
A second error was uncovered when Pickering looked into the bill. He said UTMB’s chargemaster had been updated a few months earlier and the vaccine prices for those who do not receive shots through the children’s vaccine program were listed at incorrectly high amounts, resulting in the price Nguyen’s son was charged.
Pickering said the prices had been corrected, though he declined to cite exact figures.
Because of gaps in their insurance coverage and what an official with the health provider described as billing errors by the primary care clinic, the Nguyen family of Galveston, Texas, ended up owing nearly $5,000 for checkups and immunizations for their three children. That included about $1,400 for an MMRV vaccine for 4-year-old Anh Hoang, administered amid the ongoing measles outbreak.
Credit:
Scott Dalton for KFF Health News
The resolution
In addition to contacting the insurer, Nguyen reached out to the financial offices at UTMB, asking for a reduction or waiver of the fees.
In mid-May, UTMB sent Nguyen a revised bill for his son’s office visit. It applied a 50% self-pay discount, which its website says is offered to those who are uninsured. His revised total was $1,266, $711 of which was for the MMRV vaccination.
“I expected them to waive the vaccination cost for my children or at least reduce it more, especially for MMRV vaccine,” said Nguyen, noting that his family would still be strapped trying to pay their bills.
After Pickering spoke with KFF Health News, a customer service representative reached out to Nguyen, waiving the cost of the vaccines. His new bill was $202.75 for his son’s office visit, as well as similarly smaller amounts for his daughters’ medical care.
The takeaway
Medical billing experts say it’s always a good idea to check with your insurer before elective treatments like checkups or vaccinations to find out what is covered and how much you might owe.
International students and others who purchase non-ACA-compliant plans, such as short-term coverage, should carefully review their benefits, because there are often limitations.
For some services, including vaccinations, there may be lower-cost options.
Constance Almendarez, the immunization manager for the Galveston County Health District, said in an email that many public health departments, including Galveston’s, offer free vaccinations through the children’s vaccine program to those 18 and under who are eligible, including people without insurance or whose insurance does not cover vaccines.
But those programs are potentially threatened as the Trump administration institutes layoffs of federal workers and moves to cancel grants to health departments.
Finally, you can ask for a discount. Medical providers may offer self-pay discounts for patients who are uninsured or underinsured, or charity care policies to those who meet specified income requirements.
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