Flu Shot Co-Pays: Patients Pay More as Federal Vaccine Panel Stays Empty

Insurers are not covering a new mRNA flu vaccine because the federal panel that recommends shots to health plans is empty. A judge ruled in 2025 that the committee’s recent restructuring was procedurally flawed, halting the changes. HHS Secretary Robert F. Kennedy Jr. has not nominated new members to replace the removed experts. As a result, the Advisory Committee on Immunization Practices, or ACIP, has issued no new guidance since the court order. This gap leaves health plans without a clear deadline to add coverage for vaccines approved by the Food and Drug Administration.

The cost falls directly on patients. Ron Kroening, a 63-year-old retiree from Oklahoma, was advised by his doctor to take Moderna’s mRNA flu vaccine. The FDA approved this shot for adults 50 and older in August. Clinical trials indicated the vaccine provides stronger protection than traditional flu shots. Kroening found the product at a single local pharmacy. His insurance plan denied coverage, citing the lack of an ACIP recommendation. He paid a $40 co-pay out of pocket.

Under standard industry rules, insurers typically have one year from an ACIP recommendation to cover a vaccine by the next plan year. A recommendation issued in December 2026 would require coverage by January 2028. A decision made in January 2027 would push full coverage to January 2029. Lindsay Wiley, a law professor at UCLA, noted that the legal requirement does not activate immediately. She described a recommendation in the coming year as the best case scenario, but stated there is no reason to expect one soon.

The situation differs for COVID-19 vaccines, which Congress mandated be covered within 15 days of an ACIP recommendation under the Affordable Care Act. Other vaccines face state-level hurdles. Some states prohibit pharmacists from administering vaccines without an ACIP recommendation. The court also voided a September 2025 recommendation regarding new RSV shots, though many insurers continue to cover those doses. A vacated vote to end the universal hepatitis B birth dose is now influencing state legislative proposals. Medicare coverage for the new flu shots for seniors has also been delayed, despite legal requirements that do not depend on ACIP action.

The government has appealed the portion of the ruling that disbanded the committee. Aaron Siri, who served as Kennedy’s lawyer, wrote on Monday that the White House and the Department of Justice are not making a serious effort to revive the panel. Dorit Reiss, a vaccines expert at UC Law San Francisco, agreed that the administration is choosing to keep ACIP empty. She suggested the vacancy may suit Kennedy, whose previous appointees did not move fast enough to alter the vaccination schedule. Bypassing the committee allows him to issue his own recommendations without committee consensus.

Reiss warned that trust in the committee’s independence has been undermined. Restoring the body may require new statutory protection to ensure its future stability. Kroening’s insurer is part of the Association of Health Insurance Plans, or AHIP, which has pledged to cover shots recommended as of September 2025. Insurers can voluntarily cover vaccines before they are legally required to do so. Kroening said he would choose the new vaccine again and is glad he paid for it, though he is unhappy that his insurance did not. He described the current state of vaccination policy as a mess.