AAFP Pushes CMS to Cover Certain Vaccines Under Medicare Part B

Academy Also Calls for Congressional Leaders to Up the Pressure

June 11, 2015 09:40 am News Staff
[Middle aged man getting vaccinated]

The AAFP recently doubled down on its efforts to ensure that Medicare patients have access to the vaccines they need and that family physicians get paid to administer those vaccines.

On May 28, AAFP Board Chair Reid Blackwelder, M.D., of Kingsport, Tenn., fired off letters to CMS and three congressional committees with a list of demands regarding Medicare Part B coverage of the herpes zoster vaccine; the tetanus toxoids, diphtheria and acellular pertussis (Tdap) vaccine; and other vaccines recommended by the Advisory Committee on Immunization Practices (ACIP).

In the letter(2 page PDF) to CMS Acting Administrator Andy Slavitt, Blackwelder declared that costs associated with the zoster vaccine and the recommended one-time dose of Tdap -- including the cost for physicians to administer the vaccines -- should be covered under Medicare Part B. Furthermore, payment should be retroactive to the time each associated ACIP recommendation was made, he said.

Story Highlights
  • AAFP Board Chair Reid Blackwelder, M.D., recently leaned on CMS and three congressional committees to address Medicare Part B coverage for recommended vaccines.
  • The AAFP contended that Part B should provide coverage of the herpes zoster vaccine and other vaccines recommended by the Advisory Committee on Immunization Practices.
  • Blackwelder pointed out that the Medicare Improvements for Patients and Providers Act of 2008 provided a mechanism for HHS and CMS to ensure Medicare patients had access to preventive vaccines through Medicare Part B, but CMS has failed to use its authority to do so.

Blackwelder based his argument on that fact that the U.S. Preventive Services Task Force (USPSTF) includes a reference to ACIP-recommended vaccines(www.ahrq.gov) as part of its Clinical Guide to Preventive Services,(www.ahrq.gov) which encompasses all of the clinical preventive services the USPSTF has given an "A" or "B" recommendation.

In that section of the guide, the task force specifically calls out the importance of routine immunization in primary disease prevention, while noting that it "does not wish to duplicate the significant investment of resources made by others to review new evidence on immunizations in a timely fashion and make recommendations."

Thus, it's clear that the USPSTF is relying on the ACIP for guidance on routine administration of childhood and adult vaccines, said Blackwelder, and that "ACIP's recommendations for the coverage of preventive vaccines are considered to be the 'gold-standard' for coverage policies."

Congress provided the "necessary mechanism" for HHS and CMS to ensure Medicare patients had ready access to these vaccines when it passed the Medicare Improvements for Patients and Providers Act (MIPPA) of 2008, which grants CMS authority "to include all recommended preventive vaccines within the 'additional preventive services' eligible for coverage under Medicare Part B," said Blackwelder in his letter.

"To qualify, the services must first be recommended by the U.S. Preventive Services Task Force (USPSTF) and then assessed under Medicare's national coverage determination process," he added.

But Blackwelder wasn't finished; he also called on CMS to

  • develop educational materials for both physicians and patients regarding the administration of ACIP-recommended vaccines in family physicians' offices, and
  • weigh the role that federally qualified health centers and rural health centers play in ensuring that Medicare patients have access to these vaccines and consider these sites as it examines vaccine payment policies.

The AAFP directed a similarly stern message to six U.S. congressmen.

In a letter(2 page PDF) addressed to the chairs and ranking members of the U.S. Senate Finance Committee, the House Ways and Means Committee, and the House Energy and Commerce Committee, Blackwelder reminded the legislators that it was Congress that provided the regulatory pathway to provide Medicare patients these preventive vaccines under Part B.

Yet despite the AAFP's repeated calls for action, "CMS has thus far declined to use this authority." For Congress to urge HHS and CMS to use the authority already granted to them would be "invaluable" he said.

As a second option, Blackwelder suggested Congress pass legislation to create a new benefit category that would explicitly include the zoster vaccine and all other ACIP-recommended vaccines under Medicare Part B. He noted that influenza, pneumococcal and hepatitis B vaccines already were similarly covered.

Blackwelder pointed out the inconvenience and undue hardship that Medicare patients endure as they are forced to navigate not one but two complicated federal programs -- Medicare Part B and Part D -- just to ensure they are covered to receive federally recommended vaccines.

The entire process "makes getting vaccinated needlessly complicated for these beneficiaries and the physicians who seek to serve them," said Blackwelder.

He admonished members of the committees to ease the administrative burdens family physicians encounter every day as they work to provide the best health care to their patients -- care that includes the administration of important preventive vaccinations.

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