A new nationally representative KFF Women’s Health Survey, which explores the extensive implications of Roe v. Wade being overturned by the Supreme Court, reveals that one in seven (14%) women of reproductive age report having had an abortion at some point in their life. Across partisanship, similar shares of Republican women (12%), Democratic women (14%), and independents (15%) report having had an abortion.

The survey uncovered concern over access to abortion services in emergencies. More than six in 10 women of reproductive-age (18-49 years old) across the United States (63%) are concerned that they, or someone close to them, would not be able to get an abortion if it was needed to preserve their life or health. They are also concerned that abortion bans may affect the safety of a potential future pregnancy for themselves or someone close to them (64%).

Nationally, three-quarters of reproductive-age women who are Democrats and six in 10 independent women are concerned about abortion access in cases of pregnancy-related emergencies. A sizable minority of Republican women in this age group nationally (42%) also share these concerns.

A cross-partisan trend emerged in whether abortion policy should be left up to individual states, a policy that former President Trump has said he supports, which allows the current bans and restrictions to stay in effect across half the country. The survey shows that seven in 10 reproductive-age women (74%) oppose leaving abortion policy up to the individual states to determine, including most Republicans (53%), Democrats (86%), and independents (73%).

In addition, many women across the U.S. are unaware of the status of abortion policy in their state (45%), how to obtain an abortion if they need one in the near future (26%), or that people in their state can get medication abortion pills online (19%). Since Roe v. Wade was overturned, the landscape involving abortion bans and restrictions at the state level has been shifting rapidly.

The survey also explores the abortion experiences and perspectives of women in Florida—where it is on the ballot this November—and Arizona, a swing state that may have an abortion ballot initiative this fall. Nearly one in five (18%) reproductive-age women in Florida report they have had an abortion. Among women of reproductive-age in Arizona, 15% say they have had an abortion at some point in their lives. Seven in 10 women in Arizona (70%) and Florida (72%) say abortion should be legal in all or most cases.

Additional findings include:

• In Florida, only one in five (18%) are aware medication abortion is still legal in their state (abortion is available until six weeks in Florida). About a third (34%) don’t know where to get an abortion or where to find the information should they need one, and only one in ten (9%) are aware that medication abortion pills can be obtained online. Awareness is similarly limited in Arizona (where abortion is currently available up to 15 weeks), particularly among women with lower incomes who are affected disproportionately by restrictions on abortion, have lower awareness about abortion access in their state, and have more significant concerns about pregnancy safety.
• The fallout from the overturning of Roe v. Wade has resulted in a substantial number of women who report struggling themselves—or knowing someone who struggled—to get an abortion. Nearly one in ten (8%) women of reproductive age in the United States personally know someone, including themselves, who has had difficulty getting an abortion since Roe v. Wade was overturned, including 11% of Hispanic women and 13% of women living in states with abortion bans. Among the barriers cited were traveling out of state for care, not knowing where to go, and lacking the money to cover the cost.
• Across the United States, 17% of reproductive-age women report changing their contraceptive practices as a result of Roe v. Wade being overturned. Actions taken include starting birth control, getting a sterilization procedure, switching to a more effective method, or purchasing emergency contraceptive pills to have on hand.

Periodically conducted since 2001, this 2024 KFF Women’s Health Survey analysis includes a nationally representative sample of 3,901 women ages 18 to 49. The survey was fielded from May 15 to June 18, 2024, and was developed and analyzed by KFF staff.

Read the three reports:

Abortion Experiences, Knowledge, and Attitudes Among Women in the U.S.: Findings from the 2024 KFF Women’s Health Survey

Women and Abortion in Florida: Findings from the 2024 KFF Women’s Health Survey 

Women and Abortion in Arizona: Findings from the 2024 KFF Women’s Health Survey 

Medicare Advantage plans denied 3.4 million prior authorization requests for health care services in whole or in part in 2022, or 7.4% of the 46.2 million requests submitted on behalf of enrollees that year, according to a new KFF analysis of federal data.

That was a higher share of denials than in recent years. The share of all prior authorization requests denied by Medicare Advantage plans increased from 5.7% in 2019, 5.6% in 2020 and 5.8% in 2021.

Prior authorization is intended to ensure that health care services are medically necessary by requiring providers to obtain approval before a service or other benefit is covered. While prior authorization has long been used to contain spending and prevent people from receiving unnecessary or low-value services, it also has been subject to criticism that it may create barriers to receiving necessary care. (Traditional Medicare does not require prior authorization except for a limited set of services.)

Prior authorization practices have attracted the attention of the Biden Administration and lawmakers in Congress. The administration recently finalized rules to increase the timeliness and transparency of prior authorization decisions and require Medicare Advantage plans to evaluate the effect of prior authorization policies on people with certain social risk factors. Lawmakers have introduced bills to codify many of these changes into law.

Other key takeaways from the KFF analysis include:

• Just one in 10 (9.9%) prior authorization requests that were denied were appealed in 2022. That represents an increase since 2019, when 7.5% of denied prior authorization requests were appealed.
• The vast majority of appeals (83.2%) in 2022 resulted in overturning the initial decision, similar to the shares overturned and in each year between 2019 and 2021.
• Patients may have different experiences depending on the Medicare Advantage plan in which they are enrolled. The volume of prior authorization determinations varied across Medicare Advantage insurers, as did the share of requests that were denied, the share of denials that were appealed, and the share of decisions that were overturned upon appeal.

Two other KFF analyses released today also examine the latest data about Medicare Advantage.

• The first provides information and trends about current Medicare Advantage enrollment, by plan type and firm, and by state and county. It shows that in 2024, more than half (54%) of eligible Medicare beneficiaries are enrolled in Medicare Advantage. The share of beneficiaries in Medicare Advantage plans varies across states ranging from 2% in Alaska to 63% in Alabama, Connecticut and Michigan. Medicare Advantage enrollment is highly concentrated among a small number of firms, with UnitedHealthcare and Humana accounting for nearly half (47%) of all Medicare Advantage enrollment nationwide.
• The second companion analysis describes Medicare Advantage premiums, out-of-pocket limits, supplemental benefits offered, and prior authorization requirements. In 2024, three quarters (75%) of enrollees in individual Medicare Advantage plans with prescription drug coverage pay no premium other than the Medicare Part B premium, which is a big selling point for many beneficiaries. Most Medicare Advantage enrollees are in plans that offer supplemental benefits not covered by traditional Medicare, such as vision, hearing and dental. And nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services.

Medicare Advantage enrollment has been on a steady climb for the past two decades following changes in policy designed to encourage a robust role for private plan options in Medicare. After a period of some instability in terms of plan participation and enrollment, The Medicare Modernization Act of 2003 created stronger financial incentives for plans to participate in the program throughout the country and renamed private Medicare plans Medicare Advantage. In 2024, 32.8 million people are enrolled in a Medicare Advantage plan, accounting for more than half, or 54 percent, of the eligible Medicare population, and $462 billion (or 54%) of total federal Medicare spending (net of offsetting receipts, such as premiums). Medicare Advantage enrolls a disproportionate share of people of color in Medicare as well as an increasing number of dual eligible beneficiaries. The average Medicare beneficiary in 2024 has access to 43 Medicare Advantage plans, the same as in 2023, but more than double the number of plans offered in 2018.

The growth in Medicare Advantage enrollment is due to a number of factors, including the availability of plans that charge no premium (other than the Part B premium), and extra benefits offered by most Medicare Advantage plans. Nearly all Medicare Advantage plans offer some benefits not included in traditional Medicare, such as coverage of dental, vision, or hearing services, often for no additional premium. Medicare beneficiaries are also drawn to the financial protection that comes with an out-of-pocket limit, which Medicare Advantage plans are required to provide, while traditional Medicare has no out-of-pocket cap on spending. On the other hand, Medicare Advantage plans have limited provider networks and apply cost management tools such as prior authorization, which traditional Medicare does not.

Generally, research shows that Medicare pays more to private Medicare Advantage plans for enrollees than their costs would be in traditional Medicare. The Medicare Payment Advisory Commission (MedPAC) reports that plans receive payments from CMS that are 122% of spending for similar beneficiaries in traditional Medicare, on average, translating to an estimated $83 billion in higher spending in 2024. As Medicare Advantage takes on a more dominant presence in the Medicare program, and with current payments to plans higher for Medicare Advantage than for traditional Medicare for similar beneficiaries, policymakers have become increasingly focused on how well Medicare’s current payment methodology for Medicare Advantage is working to enhance efficiency and hold down beneficiary costs and Medicare spending.

To better understand trends in the growth of the program, this brief provides current information about Medicare Advantage enrollment, by plan type and firm, and shows how enrollment varies by state and county. A second, companion analysis describes Medicare Advantage premiums, out-of-pocket limits, supplemental benefits offered, and prior authorization requirements in 2024. This analysis does not provide detailed information by enrollee characteristics, such as race/ethnicity, income, or dual status, because that information is not available.

Highlights for 2024:

• More than half (54%) of eligible Medicare beneficiaries are enrolled in Medicare Advantage in 2024. The share of Medicare beneficiaries in Medicare Advantage plans varies across states, ranging from 2% to 63%. In 7 states, AL, CT, MI, HI, ME, FL, RI (and Puerto Rico), 60% or more of all Medicare beneficiaries are enrolled in Medicare Advantage plans, an increase from 3 states in 2023.
• More than one-third (37%) of Medicare beneficiaries live in a county where at least 60 percent of all Medicare beneficiaries are enrolled in Medicare Advantage plans. Three counties (excluding those in Puerto Rico) enroll 80% or more of Medicare beneficiaries in Medicare Advantage plans: Monroe County, NY (Rochester; 82%), Starr, Texas (81%), and Miami-Dade County, Florida (80%). At the same time, 8 percent of all Medicare beneficiaries nationwide live in a county with relatively low enrollment, where less than one third of all Medicare beneficiaries are enrolled in Medicare Advantage plans. The wide variation in county enrollment rates reflect several factors, such as differences in firm strategy, urbanicity of the county, Medicare payment rates, number of Medicare beneficiaries, health care use patterns, and historical Medicare Advantage market penetration.
• Medicare Advantage enrollment is highly concentrated among a small number of firms, with UnitedHealthcare and Humana accounting for nearly half (47%) of all Medicare Advantage enrollees nationwide. In more than a quarter of all U.S. counties (29%; or 931 counties), these two firms account for at least 75 percent of Medicare Advantage enrollment. Since 2017, the market share for UnitedHealthcare and CVS Health has increased (25% to 29% and 8% to 12%, respectively), Humana (18%) and Cigna (2%) have held steady, while other firms’ share of total enrollment has slightly decreased (Blue Cross Blue Shield (BCBS) affiliates, Kaiser Permanente, and Centene). Small firms (which each account for less than 2% of enrollment) have a smaller share of the market in 2024 than in 2017 (19% to 16%).

More than half of eligible Medicare beneficiaries are enrolled in Medicare Advantage in 2024

In 2024, more than half (54%) of eligible Medicare beneficiaries – 32.8 million people out of 61.2 million Medicare beneficiaries with both Medicare Parts A and B – are enrolled in Medicare Advantage plans. Medicare Advantage enrollment as a share of the eligible Medicare population has jumped from 19% in 2007 to 54% in 2024 (Figure 1).

Between 2023 and 2024, total Medicare Advantage enrollment grew by about 2.1 million beneficiaries, or 7 percent – a similar growth rate as the prior year (8%). The Congressional Budget Office (CBO) projects that the share of all Medicare beneficiaries enrolled in Medicare Advantage plans will rise to 64% by 2034 (Figure 2).

In 2024, nearly two-thirds of Medicare Advantage enrollees are in individual plans that are open for general enrollment.

More than 6 in 10 Medicare Advantage enrollees (62%), or 20.5 million people, are in plans generally available to all beneficiaries for individual enrollment (Figure 3). That is an increase of 0.9 million enrollees compared to 2023. Individual plans have declined as a share of total Medicare Advantage enrollment since 2010 (71%).

More than 6.6 million Medicare beneficiaries are enrolled in special needs plans in 2024, more than double the enrollment in 2019.

More than 6.6 million Medicare beneficiaries are enrolled in special needs plans (SNPs). SNPs restrict enrollment to specific types of beneficiaries with significant or relatively specialized care needs, or who qualify because they are eligible for both Medicare and Medicaid. Enrollment in SNPs increased by 16 percent between 2023 and 2024, and accounts for 20 percent of total Medicare Advantage enrollment in 2024, an increase from 12 percent in 2010. Since 2019, SNP enrollment has more than doubled from 2.92 million to 6.64 million (Figure 4). This increase is due in part to the increasing number of SNP plans  available on average and more dual eligible individuals having access to these plans.

Most SNP enrollees (88%) are in plans for beneficiaries dually enrolled in both Medicare and Medicaid (D-SNPs). Another 10 percent of SNP enrollees are in plans for people with severe chronic or disabling conditions (C-SNPs) and 2 percent are in plans for beneficiaries requiring a nursing home or institutional level of care (I-SNPs).

While D-SNPs are designed specifically for dually-eligible individuals, 1.2 million Medicare beneficiaries with full Medicaid benefits were enrolled in Medicare Advantage plans generally available to all beneficiaries (not designed specifically for this population) in 2021, while 2.3 million full dual eligible individuals were in D-SNPs. D-SNPs have increasingly become the main source of Medicare Advantage coverage for dual eligible individuals.

SNP enrollment varies across states. In the District of Columbia and Puerto Rico, SNP enrollees comprise about half of all Medicare Advantage enrollees (49% in DC and 51% in PR). In nine states, SNP enrollment accounts for at least a quarter of Medicare Advantage enrollment: 46% in MS, 34% in AR, 33% in LA and NY, 28% in FL and GA, and 25% in CT, SC and AL.

C-SNP enrollment in 2024 (about 675,000 people) is 45% higher than it was in 2023 – an increase of about 210,000 enrollees. Nearly all (97%) C-SNP enrollees are in plans for people with diabetes or cardiovascular conditions in 2024. Enrollment in I-SNPs has been increasing slightly, with approximately 115,000 enrollees in 2024, up from about 103,000 in 2023.

Slightly less than one in five (17% or about 5.7 million) Medicare Advantage enrollees are in a group plan offered to retirees by an employer or union.

Group enrollment as a share of total Medicare Advantage enrollment has fluctuated between 17% to 20% since 2010, but the actual number has increased from 1.8 million in 2010 to 5.7 million in 2024 (Figure 5). With a group plan, an employer or union contracts with an insurer and Medicare pays the insurer a fixed amount per enrollee to provide benefits covered by Medicare. For example, 13 states provide health insurance benefits to their Medicare-eligible retirees exclusively through Medicare Advantage plans.

As with other Medicare Advantage plans, employer and union group plans may provide additional benefits and/or lower cost sharing than traditional Medicare and are eligible for bonus payments if they obtain required quality scores. The employer or union (and sometimes the retiree) may also pay an additional premium for these supplemental benefits. Group enrollees comprise a quarter or more of Medicare Advantage enrollees in nine states: Alaska (100%), Michigan (38%), New Jersey (33%), West Virginia (31%), Maryland (30%), Illinois (29%), Vermont (27%), Kentucky (26%), and Connecticut (25%).

The share of Medicare beneficiaries in Medicare Advantage plans varies by state and county

The share of Medicare beneficiaries in Medicare Advantage plans varies across states, ranging from 2% to 63%.

In 30 states, Medicare Advantage enrollees account for more than half of all Medicare beneficiaries, including in 7 states, AL, CT, MI, HI, ME, FL, RI (and Puerto Rico) where 60% or more of all Medicare beneficiaries are enrolled in Medicare Advantage plans (Figure 6). In contrast, Medicare Advantage enrollment is relatively low (less than 40%) in 13 states, including five states with less than 30% of beneficiaries enrolled in a Medicare Advantage plan – AK, MD, ND, SD, and WY – all of which (beside MD) are mostly rural. Overall, Puerto Rico has the highest Medicare Advantage penetration, with 95 percent of Medicare beneficiaries enrolled in a Medicare Advantage plan. A decade ago, the share of Medicare beneficiaries in Medicare Advantage plans did not exceed 50 percent in any state (other than Puerto Rico).

The share of Medicare beneficiaries enrolled in Medicare Advantage varies widely across counties.

For example, in Florida, 60% of all Medicare beneficiaries in the state are enrolled in Medicare Advantage, ranging from 21% in Monroe County (Key West) to 80% in Miami-Dade County (Figure 7). In Ohio, 57% of all Medicare beneficiaries are enrolled in Medicare Advantage, with the share ranging from 32% in Mercer County (Celina) to 69% in Stark County (Canton).

In 2024, more than a third (37%) of Medicare beneficiaries live in a county where at least 60 percent of all Medicare beneficiaries in that county are enrolled in Medicare Advantage plans (618 counties). That is substantially more than in 2010 when just 3 percent of the Medicare population lived in a county where 60 percent or more of Medicare beneficiaries were enrolled in a Medicare Advantage plan (83 counties). Many counties with high Medicare Advantage penetration are centered around relatively large, urban areas, such as Monroe County, NY (82%), which includes Rochester, and Allegheny County, PA (74%), which includes Pittsburgh. In contrast, 8 percent of Medicare beneficiaries live in a county where less than one third of all Medicare beneficiaries in that county are enrolled in Medicare Advantage plans (849 counties). Counties with relatively low enrollment tend to be less populated rural areas. However, others, such Montgomery County, MD (27%) and Suffolk, NY (31%), which includes much of Long Island, are in more populous areas. (This county-level analysis excludes Medicare Advantage enrollment in Connecticut. See methods for more details.)

Variation in the share of eligible Medicare beneficiaries who are enrolled in a Medicare Advantage plan is explained by a combination of factors, including firm-level strategies to target particular geographic areas, the urbanicity of the county and state, variation in Medicare payment rates, the number and characteristics of people eligible for Medicare, health care use patterns, and the historical Medicare Advantage market penetration.

Medicare Advantage enrollment is highly concentrated among a small number of firms

The average Medicare beneficiary is able to choose from Medicare Advantage plans offered by 8 firms in 2024, one fewer than in 2023 and 2022, and one-third of beneficiaries (33%) can choose among Medicare Advantage plans offered by 10 or more firms.

UnitedHealthcare and Humana account for nearly half of all Medicare Advantage enrollees nationwide in 2024.

Despite most beneficiaries having access to plans operated by several different firms, Medicare Advantage enrollment is highly concentrated among a small number of firms. UnitedHealthcare, alone, accounts for 29% of all Medicare Advantage enrollment in 2024, or 9.4 million enrollees. Together, UnitedHealthcare and Humana (18%) account for nearly half (47%) of all Medicare Advantage enrollees nationwide, the same as in 2023. In more than a quarter of counties (29%; or 931 counties), these two firms account for at least 75% of Medicare Advantage enrollment. These counties include East Baton Rouge (Baton Rouge), LA (81%), Clark County (Las Vegas), NV (79%), Travis County (Austin), FL (78%), and El Paso County (Colorado Springs), CO (76%). (Again, this county-level analysis does not include Connecticut.)

BCBS affiliates (including Anthem BCBS plans) account for 14% of enrollment, and four firms (CVS Health, Kaiser Permanente, Centene, and Cigna) account for another 23% of enrollment in 2024.

UnitedHealthcare and Humana have consistently accounted for a relatively large share of Medicare Advantage enrollment.

UnitedHealthcare has had the largest share of Medicare Advantage enrollment and largest growth in enrollment since 2010, increasing from 20 percent of all Medicare Advantage enrollment in 2010 to 29 percent in 2024. Humana has also had a high share of Medicare Advantage enrollment, though its share of enrollment has grown more slowly, from 16 percent in 2010 to 18 percent in 2024. BCBS plans share of enrollment has been more constant over time but has declined moderately since 2014.

CVS Health, which purchased Aetna in 2018, has seen its share of enrollment double from 6 percent in 2010 to 12 percent in 2024. Kaiser Permanente now accounts for 6 percent of total enrollment, a moderate decline as a share of total Medicare Advantage enrollment since 2010 (9%), mainly due to the growth of enrollment in plans offered by other insurers and only a modest increase in enrollment growth for Kaiser Permanente over that time. However, for those insurers that have seen declines in their overall share of enrollment, the actual number of enrollees for each insurer is larger than it was in 2010.

By absolute numbers, CVS Health had the largest growth in plan year enrollment, increasing by 758,000 beneficiaries between March 2023 and March 2024. Humana had the second largest growth in plan year enrollment, with an increase of about 472,000 beneficiaries between March 2023 and March 2024. UnitedHealthcare plans had the third highest growth in plan year enrollment, increasing by 456,000 beneficiaries – the first time in 8 years it did not have the largest plan growth among all firms. BCBS plans had the fourth largest growth in plan enrollment with an increase of about 283,000, followed by Kaiser Permanente, increasing by about 45,000 beneficiaries between March 2023 and March 2024. However, Centene had fewer enrollees, with enrollment declining by about 202,000 between March 2023 and March 2024.

People with Medicare have the option of receiving their Medicare benefits through the traditional Medicare program administered by the federal government or through a private Medicare Advantage plan, such as an HMO or PPO. In Medicare Advantage, the federal government contracts with private insurers to provide Medicare benefits to enrollees. Medicare pays insurers a set amount per enrollee per month, which varies depending on the county in which the plan is located, the health status of the plan’s enrollees, and the plan’s estimated costs of covering Medicare Part A and Part B services.

The plans use these payments to pay for Medicare-covered services, and in most cases, also pay for supplemental benefits, reduced cost sharing and lower out-of-pocket limits, which are attractive to enrollees. Plans are able to offer these additional benefits, often without charging an additional premium for Part D prescription drugs or supplemental benefits, because they receive an additional $2,329 per enrollee above their estimated costs of providing Medicare-covered services. This portion of plan payments, also called the rebate, has increased substantially in the last several years, more than doubling since 2018. At the same time, Medicare Advantage plans can use cost management tools, such as prior authorization requirements, which can impose barriers to receiving care, and limited networks of providers, which can restrict beneficiary choice of physicians and hospitals. More than half (56%) of Medicare Advantage beneficiaries are enrolled in HMO plans that typically do not cover out-of-network services.

This brief provides information about Medicare Advantage plans in 2024, including premiums, out-of-pocket limits, supplemental benefits, and prior authorization, as well as trends over time. A companion analysis examines trends in Medicare Advantage enrollment.

While data on Medicare Advantage plan availability, enrollment and plan offerings is robust, the same cannot be said about service utilization (especially for supplemental benefits) and out-of-pocket spending patterns (though some of this data is starting to be collected), which would allow assessment of how well the program is meeting its goals in terms of value and quality and help Medicare beneficiaries compare coverage options. As enrollment in Medicare Advantage and federal payments to private plans continue to grow, greater transparency and more comprehensive information will become increasingly relevant for people with Medicare program oversight.

Highlights for 2024:

• In 2024, three quarters (75%) of enrollees in individual Medicare Advantage plans with prescription drug coverage pay no premium other than the Medicare Part B premium, which is a big selling point for beneficiaries, particularly those living on modest incomes and savings.
• Most Medicare Advantage enrollees are in plans that offer supplemental benefits not covered by traditional Medicare, such as vision, hearing and dental. From 2023 to 2024, Medicare Advantage enrollees overall did not experience a significant loss in benefits despite concerns that changes in Medicare Advantage payment would lead to a drastic reduction in benefits or increase in premiums, though there were small declines in the share of enrollees in plans with access to some benefits from 2023 to 2024.
• Nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services, which is generally not used in traditional Medicare. Prior authorization is most often required for relatively expensive services, such as skilled nursing facility stays (99%), Part B drugs (98%), inpatient hospital stays (acute: 98%; psychiatric: 93%) and outpatient psychiatric services (82%) and is rarely required for preventive services (6%).

In 2024, three quarters of Medicare Advantage enrollees (75%) are in plans with no supplemental premium (other than the Part B premium)

In 2024, most people (75%) enrolled in individual Medicare Advantage plans with prescription drug coverage (MA-PDs) pay no premium other than the Medicare Part B premium ($174.70 in 2024) (Figure 1). The MA-PD premium includes both the cost of Medicare-covered Part A and Part B benefits and Part D prescription drug coverage. In 2024, 97% of Medicare Advantage enrollees in individual plans open for general enrollment are in plans that offer prescription drug coverage.

Altogether, including those who do not pay a premium, the average enrollment-weighted premium in 2024 is $14 per month, and averages $9 per month for just the Part D portion of covered benefits, substantially lower than the average premium of $43 for stand-alone prescription drug plans (PDP) in 2024. Higher average PDP premiums compared to the MA-PD drug portion of premiums is due in part to the ability of MA-PD sponsors to use rebate dollars from Medicare payments to lower their Part D premiums. When a plan’s estimated costs for Medicare-covered services are below the maximum amount the federal government will pay private plans in an area (known as the benchmark), the plan retains a portion of the difference, known as the “rebate”. According to the Medicare Payment Advisory Commission (MedPAC), rebates average over $2,300 per enrollee in 2024.

For the remaining 25% of beneficiaries who are in plans with a MA-PD premium (5.0 million), the average premium is $56 per month, and averages $36 for the Part D portion of covered benefits.

Premiums paid by Medicare Advantage enrollees have declined since 2015.

Average MA-PD premiums have declined from $36 per month in 2015 to $14 per month in 2024. Average MA-PD premiums have declined markedly for local PPOs, declining from $65 per month in 2015 to $16 per month in 2024. Premiums for HMOs have also declined steadily from $28 per month in 2015 to $12 per month in 2024. Only regional PPOs, which represent a very small and declining share of enrollment, have seen an increase in plan premiums over this time from $36 per month in 2015 to $55 per month in 2024. Nearly 6 in 10 Medicare Advantage enrollees are in HMOs (56%), 43% are in local PPOs, and 1% are in regional PPOs in 2024. The reduction for nearly all plans is driven in part by the decline in premiums for local PPOs and HMOs, that account for a rising share of enrollment over this time period, as well as the increase in rebates paid by Medicare to these plans.

Since 2015, a rising share of plans estimate that their cost of providing Medicare Part A and Part B services (the “bid”) is below the maximum amount that CMS will pay in the area where the plan operates (the “benchmark”). The difference between bids and benchmarks enables plans to offer coverage that typically includes extra benefits without charging an additional premium. As plan bids have declined, the rebate portion of plan payments has increased, and plans are allocating some of those rebate dollars to lower the part D portion of the MA-PD premium. According to MedPAC, rebates have increased from an average of about $900 per enrollee in 2015 to over $2,300 per enrollee in 2024. This trend contributes to greater availability of zero-premium plans, which brings down average premiums.

The average out-of-pocket limit for Medicare Advantage enrollees is $4,882 for in-network services and $8,707 for both in-network and out-of-network services (PPOs).

Since 2011, federal regulation has required Medicare Advantage plans to provide an out-of-pocket limit for services covered under Parts A and B. In contrast, traditional Medicare does not have an out-of-pocket limit for covered services.

In 2024, the out-of-pocket limit for Medicare Advantage plans may not exceed $8,850 for in-network services and $13,300 for in-network and out-of-network services combined. These out-of-pocket limits apply to Part A and B services only, and do not apply to Part D spending. Due to a provision in the Inflation Reduction Act, there is a cap in Part D spending of around $3,300 in 2024, and in 2025, Medicare beneficiaries will pay no more than $2,000 out of pocket for prescription drugs covered under Part D.

HMOs generally only cover services provided by in-network providers so typically do not have a limit for out-of-network services. However, about 5 million Medicare Advantage enrollees are in HMOs that are Point-of-Service plans (HMOPOS), which allow out-of-network care for certain services, though they typically cost more than services received in-network. PPOs also cover services delivered by out-of-network providers but charge enrollees higher cost sharing for this care. The size of Medicare Advantage provider networks for physicians and hospitals vary greatly both across counties and across plans in the same county.

In 2024, the enrollment-weighted average for out-of-pocket limits for Medicare Advantage enrollees is $4,882 for in-network services and $8,707 for in-network and out-of-network services combined. For enrollees in HMOs, the average out-of-pocket (in-network) limit is $3,965 (Figure 3). Enrollees in HMOs are generally responsible for 100% of costs incurred for out-of-network care. For local and regional PPO enrollees, the average out-of-pocket limit for both in-network and out-of-network services is $8,634, and $10,728, respectively.

The average out-of-pocket limit for in-network services has generally trended down from 2017 ($5,297), though increased slightly from $4,835 in 2023 to 4,882 to 2024. The average combined in- and out-of-network limit for PPOs slightly increased from $8,659 in 2023 to $8,707 in 2024.

Most Medicare Advantage enrollees, including enrollees in special needs plans (SNPs), are in plans that offer some benefits not covered by traditional Medicare in 2024

Virtually all enrollees in individual Medicare Advantage plans (those generally available to Medicare beneficiaries) are in plans that offer primarily health related supplemental benefits including eye exams and/or glasses (more than 99%), dental care (98%) hearing exams and/or aids (96%), and a fitness benefit (95%) (Figure 4). Similarly, most enrollees in SNPs are in plans that offer these benefits. However, benefits such as Part B drug rebate are less common for enrollees in both individual plans (12%) and SNPs (7%). This analysis excludes employer-group health plans because employer plans do not submit bids, and available data on supplemental benefits may not be reflective of what employer plans actually offer.

Though these benefits are widely available, the scope of specific services varies. For example, a dental benefit may include preventive services only, such as cleanings or x-rays, or more comprehensive coverage, such as crowns or dentures. Plans also vary in terms of cost sharing for various services and limits on the number of services covered per year, many impose an annual dollar cap on the amount the plan will pay toward covered service, and some have networks of dental providers beneficiaries must choose from.

Enrollees in SNPs have greater access than other Medicare Advantage enrollees to transportation (91% vs 36%), meal benefits (85% vs 74%), bathroom safety devices (49% vs 31%), and in-home support services (23% vs 9%). However, as noted above, it is not known what share of enrollees have used these benefits because data are not yet available.

As of 2020, Medicare Advantage plans have been allowed to include telehealth benefits as part of the basic Medicare Part A and B benefit package – beyond what was allowed under traditional Medicare prior to the public health emergency, and was extended to December 2024. Therefore, these benefits are not included in the figure above because their cost is not covered by either rebates or supplemental premiums. Medicare Advantage plans may also offer supplemental telehealth benefits via remote access technologies and/or telemonitoring services, which can be used for those services that do not meet the requirements for coverage under traditional Medicare or the requirements for additional telehealth benefits (such as the requirement of being covered by Medicare Part B when provided in-person). The majority of enrollees in both individual plans and SNPs are in plans that offer remote access technologies (72% and 78%, respectively), but just 4% of enrollees in individual plans and 1% of enrollees in SNPs have access to telemonitoring services.

Nearly all Medicare Advantage enrollees are in plans that offer vision, dental, and hearing benefits, similar to 2023, with the share of enrollees in plans that offer many benefits increasing substantially since 2015.

In 2024, there were modest changes to the share of enrollees in plans that offer specific benefits compared to 2023. Similar shares of enrollees in individual plans are in plans that offer eye exams and/or eyeglasses (100% in 2023 and 2024), dental benefits (98% in 2023 and 2024), and hearing exams and/or aids (99% in 2023 vs 96% in 2024) (Figure 5). Smaller shares of enrollees are in plans that offer transportation benefits (44% in 2023 vs 36% in 2024) while a larger share of enrollees is in plans that offer bathroom safety devices (10% in 2023 vs 31% in 2024).

For those in Special Needs Plans, similar shares of enrollees are in plans that offer eye exams and/or eyeglasses (97% in 2023 vs 98% in 2024), dental benefits (95% in 2023 and 2024), and hearing exams and/or aids (92% in 2023 vs 93% in 2024). Larger shares of SNP enrollees are in plans that offer over the counter benefits (84% in 2023 vs 96% in 2024) and bathroom safety devices (15% in 2023 vs 49% in 2024).

Overall, Medicare Advantage enrollees have not experienced a significant loss in benefits despite concerns that changes in Medicare Advantage payment would lead to a drastic reduction in benefits or increase in premiums. While the share enrolled in plans that offer benefits appears to have remained mostly stable from 2023 to 2024 and has increased substantially from 2015 for many benefits, this analysis does not account for any changes to the design of benefits, which could be less robust, even if the benefits are still offered by the plan, such as restrictions on eligibility for these benefits, narrower networks of providers or less comprehensive coverage.

Enrollees in SNPs are more likely to be in plans that offer Special Supplemental Benefits for the Chronically Ill (SSBCI) than other Medicare Advantage enrollees.

Beginning in 2020, Medicare Advantage plans have also been able to offer supplemental benefits that are not primarily health related for chronically ill beneficiaries, known as Special Supplemental Benefits for the Chronically Ill (SSBCI). In addition, Medicare Advantage plans participating in the Value-Based Insurance Design Model may also offer these non-primarily health related supplemental benefits to their enrollees, but can use different eligibility criteria than required for SSBCI, including offering them based on an enrollee’s socioeconomic status (e.g., LIS eligibility) or whether the enrollee lives in an underserved area.

The vast majority of individual plan enrollees and about half of SNP Medicare Advantage enrollees are in plans that do not offer these benefits. However, while the share in plans that are offered these benefits varies widely, this often translates to a similar number of enrollees. For example, the share of Medicare Advantage enrollees who are offered SSBCI benefits in 2024 is highest for food and produce – 15% for individual plans or about 3.1 million enrollees, while 49% of SNP enrollees are offered these benefits, or about 3.3 million enrollees (Figure 6).

The other SSBCI benefits that are most commonly offered are general supports for living (e.g., housing, utilities) (10% in individual plans and 43% for SNPs) and transportation for non-medical needs (9% for individual plans and 29% for SNPs). A similar share of enrollees in individual plans (5%) are offered pest control, a social needs benefit (e.g., community programs), and meals beyond a limited basis though the share of enrollees in SNPs who have access to these benefits is higher (17%, 15%, and 12%, respectively). Smaller shares of enrollees are in plans that offer indoor air quality equipment and services (e.g., air conditioning units) (4% in individual plans and 12% for SNPs), services supporting self-direction (e.g., power of attorney for health services, financial literacy classes) (3% in individual plans and 12% for SNPs), complementary therapies (those offered alongside traditional medical treatment) (3% in individual plans and 12% for SNPs) and structural home modifications (0.02% for individual plans and 1% for SNPs).

In addition to the 10 initially enumerated examples of SSBCI provided by CMS, plans are also able to offer “other” extra benefits specified by the plan, including pet care/service animal supplies (5% in individual plans and 18% for SNPs) and personal care (2% in individual plans and 9% for SNPs)(Figure 6). About 2% of SNP enrollees are in plans that offer roadside and travel assistance and home cleaning (less than 1% in individual plans), and less than 1% are in SNPs or individual plans that offer hairstyling and beauty care (data not shown), though this is not an exhaustive list of additional benefits plans may offer.

While the share of enrollees with plans that offer some SSBCI benefits has increased since 2021, such as food and produce, growth for other benefits has been much slower.

Though the share of SNP enrollees in plans with food and produce benefits, general supports for living benefits, and transportation for non-medical needs has grown considerably since 2021, the share of enrollment in plans for other SSBCI benefits has grown much more slowly, particularly for enrollees in individual plans (Figure 7). For example, the share of SNP Medicare Advantage enrollees with food and produce benefits in SNPs has more than doubled from 21% in 2021 to 49% in 2024, while for individual plans, the share of enrollees with these benefits has also doubled, but only from 7% to 15%. For general supports for living benefits, the share of SNP Medicare Advantage enrollees with these benefits has more than quadrupled from 10% to 43%, while for individual plans, the share has more than tripled, but only from 3% to 10%.

Like for other supplemental benefits, the scope of services for SSBCI benefits varies. For example, many plans offer a specified dollar amount that enrollees can use toward a variety of benefits, such as food and produce, utility bills, rent assistance, and transportation for non-medical needs, among others. This dollar amount is often loaded onto a flex card or spending card that can be used at participating stores and retailers, which can vary depending on the vendor administering the benefit. Depending on the plan, this may be a monthly allowance that expires at the end of each month or rolls over month to month until the end of the year, when any unused amount expires.

Nearly all Medicare Advantage enrollees are in plans that require prior authorization for many higher-cost services

Medicare Advantage plans can require enrollees to receive prior authorization before a service will be covered, and nearly all Medicare Advantage enrollees (99%) are in plans that require prior authorization for some services in 2024 (Figure 8). Prior authorization is most often required for relatively expensive services, such as skilled nursing facility stays (99%), Part B drugs (98%), inpatient hospital stays (acute: 98%; psychiatric: 93%) and outpatient psychiatric services (82%) and is rarely required for preventive services (6%). Prior authorization is also required for the majority of enrollees for some extra benefits (in plans that offer these benefits), including comprehensive dental services, and hearing and eye exams. The number of enrollees in plans that require prior authorization for one or more services stayed around the same from 2023 to 2024. In contrast to Medicare Advantage plans, traditional Medicare does not generally require prior authorization for services and does not require step therapy for Part B drugs.

Since Roe v. Wade was overturned in June 2022, there has been considerable media attention and legal scrutiny of the health and life exceptions to state abortion bans. This may emerge as an election issue as Former President Trump has stated that he supports rape exceptions to abortion bans, but the 2024 Republican party platform says states should decide their own abortion laws – with no mention of exceptions. The vast majority of Americans – about 8 in 10 – support legal access to abortion for pregnancies resulting from rape or incest. While rape and incest exceptions have been part of the political debate, the feasibility of accessing abortion care under these exceptions has garnered much less attention.

Despite broad support for legal access to abortion in cases of rape or incest, 10 of the 21 states with abortion bans or gestational limits do not have an exception for pregnancies resulting from sexual assault. In the 11 states with rape and incest exceptions, lack of provider availability, law enforcement reporting requirements, and early pregnancy gestational limits can make access to abortion care unattainable for pregnant survivors of sexual assault (Figure 1).

Rape and incest exceptions to state abortion bans or gestational limits are often restricted to abortion early in pregnancy. Among the 21 states with abortion bans or early gestational limits, 11 make exceptions for pregnancies resulting from rape or incest and 10 do not. Of the 14 states with total abortion bans, nine (Alabama, Arkansas, Kentucky, Louisiana, Missouri, Oklahoma, South Dakota, Tennessee, and Texas) lack a rape or incest exception. The remaining 5 (Idaho, Indiana, Mississippi, North Dakota, and West Virginia) have exceptions for cases of rape or incest but limit these exceptions to the earlier stages of pregnancy. Most pregnant people discover they are pregnant at 5.5 weeks LMP, though people living on lower incomes, younger people, Black and Hispanic people, and those experiencing unintended pregnancies often discover their pregnancies later. Of the 7 states with overall gestational limits between 6 and 15 weeks LMP, six (Florida, Georgia, Iowa, Nebraska, North Carolina, and South Carolina) have rape or incest exceptions. Arizona does not have a rape or incest exception in its law.

Most rape or incest exceptions require involvement of law enforcement, which can restrict abortion access for those who have become pregnant as a result sexual assault. In 5 of the states with rape or incest exceptions – Florida, Georgia, Idaho, Mississippi, and West Virginia – pregnant people must report the sexual assault to law enforcement before they can receive abortion care. Many of these states additionally require that the pregnant person provide the physician a copy of the report ahead of receiving care. In Iowa, sexual assault survivors must report the incident “to law enforcement or a public or private health agency which may include a family physician”– within 45 days of the incident (140 days for cases of incest). In South Carolina, survivors are not required to report their assault to law enforcement before receiving abortion care, but physicians who perform abortions under the rape/incest exception must report the allegation of sexual assault to the sheriff in the county in which the abortion was provided.

It is estimated that only 21% of sexual assaults are reported. Survivors are often afraid to report sexual violence to the police due to fear of retaliation and the belief that law enforcement would not do anything to help.

These requirements can also delay care. There are no clear guidelines specifying how quickly law enforcement must issue a copy of the report in these states. Advocates argue it is difficult to get a copy of a police report while the sexual assault is still being investigated. Among the states that require law enforcement reporting, only Idaho specifies that survivors of sexual assault are entitled to receiving a copy of the report within 72 hours of making the request.

Pregnant people may face difficulty finding an abortion provider or securing an appointment. In states with total abortion bans, few abortion providers remain. Providers in states with early gestational limits (and the few remaining providers in states with total bans) may be unwilling  to provide abortion care in instances of rape or incest – even when there is an exception – out of fear of prosecution. The sexual assault exceptions often do not specifically outline how physicians can ensure that they will not be prosecuted for providing an abortion that falls under the exceptions. In Idaho, Mississippi, and North Dakota clinics and abortion funds have counseled patients to leave the state to obtain abortion care because they have found that it is easier for people to obtain abortion care out of state than to attempt to receive care in-state under the exception.

It is instructive to consider a hypothetical scenario in West Virginia, an abortion ban state with a rape/incest exception.  The state’s total abortion ban has an exception for pregnancies resulting from rape or incest, but only up to 8 weeks LMP (Last Menstrual Period) for adults, typically about 4 weeks after a missed period. Because most people discover they are pregnant at 5.5 weeks LMP, a person who is pregnant as a result of rape or incest in West Virginia typically would have only 2.5 weeks to:

1. Find and secure and appointment with a physician who is willing and able to provide the abortion
2. File a report of the assault to law enforcement and retrieve a copy of the report to provide to the physician performing the abortion at least 48 hours before receiving the abortion
3. Secure sufficient funding to pay for the abortion
4. Manage other logistical challenges, such as arranging childcare and time off work.

West Virginia’s ban is layered on top of the abortion restrictions implemented before the Dobbs decision: a 24-hour waiting period, mandatory counseling, an ultrasound offer, and for minors, parental or legal guardian notification or a judge’s approval.  The flow chart below shows how tight this timing is. (Figure 2)

Medicaid coverage for abortion care may be inaccessible, even for enrollees who qualify for a rape or incest exception. Although the federal Hyde Amendment requires state Medicaid programs to cover abortions in cases where the pregnancy resulted from rape or incest, many state Medicaid programs impose pre-authorization requirements and medically unnecessary restrictions. As a result, few, if any, pregnant people obtain Medicaid coverage for their abortion care.  For low-income survivors of sexual assault, cost can be an insurmountable barrier to accessing abortion care. In 2021, the median cost of abortion services exceeded $500. However, 43% of women ages 18-49 cannot cover an emergency expense of at least $500 using their current savings, with even larger shares of Black and Hispanic women (57% and 58%, respectively) being unable to cover such an emergency medical expense.

Few people have accessed abortion care under the rape or incest exceptions to state abortion bans. While data from states with abortion bans and exceptions for rape or incest is scant, estimates show that very few abortions are provided in states with total abortion bans, even in those with sexual assault exceptions. For example, Mississippi and Idaho each had 5 documented abortions in 2023, though neither specify the exception under which the abortions were provided. In West Virginia, 23 abortions were provided from January 2023 through June 2024, but none are reported to have been provided under the state’s rape/incest exception. Since Indiana’s total ban went into effect in late August 2023, providers have reported that 5 abortions were provided due to rape or incest.  The true number of pregnancies that result from rape is unknown. Given the extremely low number of abortions states have reported as qualifying for rape exceptions to abortion bans and what is known about the high rates of sexual violence that women experience, it would appear that these exceptions have not provided the level of access to abortion for pregnant rape survivors that the laws presumably are designed to protect.

Note: This factsheet was updated on October 08, 2024 to incorporate new data on HPV vaccine utilization.The human papillomavirus (HPV) vaccine is the first and only vaccination that helps protect individuals from getting several cancers that are associated with different HPV strains. The vaccine protects young people against infection from certain strains of HPV, the most common sexually transmitted infection (STI) in the United States. Since HPV vaccines were first introduced in the U.S. in 2006, there have been changes in the range of protection they offer and the dosing regimen. The vaccines were originally recommended only for girls and young women and were subsequently broadened to include boys, young men, and people of all genders. This factsheet discusses HPV and related cancers, use of the HPV vaccines for both females and males, and insurance coverage and access to the vaccines.

HPV and Cancer

HPV is the most common STI in the U.S. and is often acquired soon after initiating sexual activity. Approximately 42.5 million Americans are infected with HPV and there are at least 13 million new infections annually. There are more than 200 known strains of HPV, and while most cases of HPV infection usually resolve on their own, persistent infection with high-risk strains can cause cancer. HPV-related cancers have increased significantly in the past two decades — between 2015 and 2019, over 47,000 people in the United States developed an HPV-related cancer compared to 30,000 in 1999. While HPV-related cervical and vaginal cancer rates have decreased since 1999, rates for oropharyngeal and anal HPV-related cancers have increased.

Cervical Cancer

HPV is related to over 90% of cervical cancer cases, with two strains (16 and 18) responsible for approximat­­ely 66% of cervical cancer cases worldwide. In the U.S., it is estimated that 13,820 new cervical cancer cases will be diagnosed in 2024. While cervical cancer is usually treatable, especially when detected early, approximately 4,360 deaths from cervical cancer will occur in 2024. Current guidelines by the U.S. Preventive Services Task Force (USPSTF) and Women’s Preventive Services Initiative (WPSI) recommend that most women ages 21 to 65 receive Pap test once every three years and recommends that women over 30 get a high-risk HPV test every 5 years.

Despite widespread availability of Pap testing, racial disparities in cervical cancer incidence and mortality rates persist in the U.S. For example, although Hispanic women have the highest incidence rate of cervical cancer, their cervical cancer mortality rates are comparable to the national mortality rate. Black women, on the other hand, have the third highest incidence rate of cervical cancer, yet have the highest mortality rates of the disease (Figure 1). One notable paradox is that Black women also have the highest rates of recent Pap testing. In 2022, 64% of Black women ages 18 to 64 reported having received a Pap smear in the past two years compared to 59% of White women, 60% of Hispanic women, and 57% of Asian women. Lower rates in follow-up treatment after an abnormal pap smear, differences in treatment options, diagnosis at later stages of disease progression, and distrust in the medical system may account for some of the disproportionate impact of cervical cancer on Black women.

More than half of cervical cancer cases are detected in women who have never been screened or have not been screened as frequently as recommended in guidelines. Higher shares of Hispanic and Black women have never been screened for cervical cancer compared to White women (14% and 12% percent, respectively, compared to 6% of White women). Additionally, Hispanic women have one of the highest uninsured rates in the country (20%) compared to 6% of White women and 10% of Black women. Compared to women with insurance, uninsured women and women with Medicaid were less likely to access preventive health services such as Pap tests in 2022.

Cervical cancer screening rates declined during the early part of the COVID-19 pandemic. While cervical cancer screening rates have rebounded to a degree, they have not returned to pre-pandemic levels. A KFF survey of OBGYNs found that 71% of physicians reported that it was difficult to provide preventive reproductive health care services, like STI and cervical cancer screenings, during the COVID-19 pandemic. In that same survey, 38% of OBGYNs said they were somewhat or very worried that their patients who experienced delays in following up on abnormal pap smears because of the pandemic would face negative health care consequences.

In May 2024, the U.S. Food and Drug Administration (FDA) approved the use of HPV self-collection methods in healthcare settings, though these methods are not yet widely available. Self-collection will allow women to collect a vaginal swab sample within a healthcare facility without having to see a gynecologist. However, they would not replace screening with pap tests or traditional HPV testing; rather, they would provide patients with a more private, comfortable, and convenient option to test for cervical cancer as well as improve earlier detection of the disease. Currently, the National Cancer Institute is conducting a study to gauge the usability, acceptability, and effectiveness of self-collection methods throughout the United States.

Oropharyngeal and Anal Cancers

Approximately 20,805 cases of oropharyngeal (throat) cancer occur annually in the U.S, most of which (70%) are probably caused by HPV. Oropharyngeal cancers are the most common HPV-associated cancer among men and are more common among men than women (Figure 2). However, it’s important to note that anyone who heavily uses both tobacco and alcohol is at much higher risk of developing these cancers. Research suggests that HPV vaccines can help protect against throat cancer, since many are associated with HPV 16 and 18, two of the strains that the vaccine protects against.

HPV is also responsible for the majority (91%) of the over 7,500 annual cases of anal cancer in the U.S. Most cases of anal cancer are among women (Figure 2), but men who have sex with men are also at higher risk of HPV strains 16 and 18. Additional risk factors for anal cancer include a history of cervical cancer and having a suppressed immune system. Like oropharyngeal cancer, there has been an increase in the rate of anal cancers in the past 15 years.

HPV Vaccines

Since 2016, Gardasil®9 is the only HPV vaccine available in the U.S. The HPV vaccine, as well as all other routine vaccines, may be administered on the same day as any of the COVID-19 vaccines.

The FDA approved first-generation Gardasil®—produced by Merck—in 2006, which prevented infection of four strains of HPV: 6, 11, 16, and 18. In December 2014, Gardasil®9 was approved by the FDA. This vaccine protects against 9 strains of HPV: the four strains approved in the previous Gardasil vaccine, as well as 31, 33, 45, 52, and 58. These strains are associated with the majority of cervical cancer, anal cancer, and throat cancer cases as well as most genital warts cases and some other HPV-associated ano-genital diseases. The vaccine was initially approved for cervical cancer prevention, but in 2020 the FDA broadened its approval to include the prevention of oropharyngeal cancer and other head and neck cancers.

Gardasil®9 has been approved by the FDA for use in individuals ages nine to 45 years (Table 1). The federal Advisory Committee on Immunization Practices (ACIP)—an independent body of experts that issues immunization recommendations for the U.S. population—recommends that all girls and boys get vaccinated at age 11 or 12, or as early as age nine, and that adolescents and young adults ages 13 to 26 be given a “catch-up” vaccination series. ACIP recommends a two-dose series over 6 to 12 months for individuals who received their first vaccine at ages nine to 14. Teens and young adults who initiate vaccination at age 15 or older should receive three doses over six months. These recommendations are designed to promote immunization when the vaccine is most effective – before the initiation of sexual activity. Those already infected with HPV can also benefit from the vaccine because it can prevent infection against HPV strains they may not have contracted, but the vaccine does not treat existing HPV infections.

While the FDA expanded it’s approval of the HPV vaccine to include adults ages 27 to 45, ACIP does not recommend routine catch-up vaccinations for all adults in this age group. ACIP recommends that adults ages 27 to 45 who have not been properly vaccinated and who may be at risk for new HPV infections consult with a medical professional about receiving the vaccine.

Current global research suggests Gardasil®9 protection is long-lasting: more than 10 years of follow-up data in both boys and girls indicate the vaccines are still effective and there is no evidence of waning protection, although it is still unknown if recipients will need a booster in the future. Other HPV vaccines show similar effectiveness. In Scotland, recipients of the bivalent HPV vaccine Cervarix®—which protects against HPV 16 and 18—who became fully vaccinated against HPV at age 12 or 13 have had no cases of cervical cancer since the vaccine program started in 2008. Additionally, new data from the American Society of Clinical Oncology shows that the vaccine reduced the risk of all HPV-associated cancers—including oropharyngeal, head, and neck cancers—by 50% in men.

Outreach and Utilization

HPV vaccination rates vary by state, from a low of 39% of adolescents being HPV UTD in Mississippi to a high of 85% in Rhode Island (Figure 3). Some states, such as Hawaii, Rhode Island, Virginia, and D.C., have laws that require HPV vaccination for school entry. In California, the Cancer Prevention Act requires schools to notify families of 6^th grade children about HPV vaccine recommendations and advise them to follow guidelines but does not require them to adhere to them for school entry. Vaccine exemptions due to religious or personal beliefs are permitted in most states.

Some people begin the vaccine series but do not complete it. In 2023, 78.5% of adolescent girls and 75% of boys received at least one dose of the HPV vaccine. Trends in vaccination coverage show that overall HPV vaccination initiation slightly declined in 2022 for the first time since 2013 among some subgroups of adolescents aged 13-17. While vaccine initiation among adolescents overall remained steady, initiation rates in 2022 decreased among adolescents who were uninsured or covered by Medicaid (Figure 4).

Data from the Vaccines for Children Program (VFC), a federally-funded program that covers the cost of ACIP-recommended vaccines for eligible populations through age 18, show that, compared to 2019, VFC provider orders for the HPV vaccine decreased from 2020 to 2022. Research suggests that the COVID-19 pandemic disrupted the delivery and administration of the HPV vaccine, as well as parents’ and patients’ abilities to attend well-child visits before vaccines became overdue, resulting in lower rates of vaccination.

Vaccine hesitancy during this time may have also contributed to the decline in HPV vaccine initiation. Prior to the COVID-19 pandemic, parents’ top reasons for not vaccinating their children were perceptions of safety concerns and the belief that the vaccine was not needed. Since the COVID-19 pandemic began, some providers have observed an increase in vaccine hesitancy or refusal in parents of adolescents due to difficulties caused by COVID-19 or mistrust in vaccines.

Compared to 2022, national HPV UTD rates among adolescents aged 13-17 remained steady in 2023, with just over 60% being up-to-date. HPV vaccination rates among teen boys are lower than for girls (59% vs. 64% HPV UTD in 2023), but they have been rapidly rising since 2016.  Although HPV UTD rates in adolescents overall has remained steady, recent data shows a decline in vaccination rates by birth year. Compared to 13-year-olds born in 2007, HPV UTD coverage in 13-year-olds born in 2010 decreased by 7.1% overall and 10.3% among those eligible for the VFC program. The Centers for Disease Control and Prevention (CDC) suggest that additional outreach focused on populations that experienced declines in vaccination is needed to further understand the impact of the COVID-19 pandemic on access to and initiation of recommended vaccines.

Vaccine Financing

There are multiple sources of private and public financing that assure that nearly all children and young adults in the U.S. have coverage for the HPV vaccine. Many of the financing entities base their coverage on ACIP recommendations.

The Affordable Care Act (ACA) requires public and private insurance plans to cover a range of recommended preventive services and ACIP recommended immunizations without consumer cost-sharing. Plans must cover the full charge for the HPV vaccine, as well as pap tests and HPV testing for women.

Public Financing

Vaccines for Children — Through the VFC program, the CDC purchases vaccines at a discounted rate and distributes them to participating healthcare providers. All children are eligible through age 18 if they are uninsured, underinsured, Medicaid-eligible, Medicaid-enrolled, or American Indian or Alaska Native.

Medicaid — Medicaid covers ACIP recommended vaccines for enrolled individuals under age 21 through the Early and Periodic Screening Diagnosis and Treatment program (EPSDT). Adults 21 and older who are insured through Medicaid are covered for approved adult ACIP-recommended vaccinations without cost-sharing.

Public Health Service Act — Section 317 of the Public Health Service Act provides grants to states and local agencies to help extend the availability of vaccines to uninsured adults in the United States. These are often directed towards meeting the needs of priority populations, such as underinsured children and uninsured adults.

Merck Vaccine Patient Assistance Program — Merck has established assistance programs to provide free vaccines in the United States. To qualify, individuals must be aged 19 or older, uninsured, and low-income.

Children’s Health Insurance Program (CHIP) — Children who qualify for CHIP are part of families whose incomes are too high to qualify for Medicaid but too low to afford private insurance. Each state has its own set of specific qualifications for CHIP. The program is managed by the states and is jointly funded by the states and the federal government. CHIP programs that are separate from the Medicaid Expansion must cover ACIP-recommended vaccines for beneficiaries since they are not eligible for coverage under the federal VFC.

The HPV vaccine has been available in the U.S. for nearly two decades and uptake has risen over that time, though more recently since the COVID-19 pandemic there have been notable declines in vaccination rates. Since its introduction in 2006, the vaccine covers more strains of HPV, its use has been extended to males, the dosage has dropped from three to two shots, and the cost is fully covered by private insurance and public programs. With these improvements, the vaccine holds the promise to safely and dramatically reduce the rates of and prevent many kinds of cancers that have long been responsible for the deaths of women and men.