Can my HMO legally avoid providing a free shingles shot by not having any in network locations or Doctors that provide this shot?

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Can my HMO legally avoid providing a free shingles shot by not having any in network locations or Doctors that provide this shot?

Can my HMO legally avoid providing a free shingles shot by not having any in
network locations or Doctors that provide this shot?

The ACA mandates that these be provided without charge at an in network
location but what if no network locations provide the shot at all?

My Dr. gave a Rx for the shingles shot and sent me to Walgreens. When I went
to Walgreens they said that my insurance would not cover the shot and that the
cost would be 234.99

Asked on December 21, 2016 under Insurance Law, Illinois

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 4 years ago | Contributor

Yes, they can legally do this, and is one of the several "loopholes" in the ACA: nothing in the Affordable Care Act requires either 1) any in-network providers/locations near you; or 2) that the in-network locations or providers they do have provide all potential services. All that is required is that IF you have an in-network provider who provides this shot, that it be done at no cost to you, but the law does not make a provider offer this shot in the first place if they don't want to.


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