Medicare updates coverage for pneumococcal vaccinations

Medicare Part B covers certain immunizations, including pneumococcal vaccines. Historically, Medicare covered pneumococcal vaccine only once in a beneficiary’s lifetime, with revaccinations covered for those at highest risk if either five years had passed since the last vaccination or the beneficiary’s vaccination history was unknown.

The Advisory Committee on Immunization Practices (ACIP) recently updated its guidelines regarding pneumococcal vaccines. The ACIP now recommends administration of two different pneumococcal vaccinations.

The Centers for Medicare & Medicaid Services, in turn, is updating the Medicare coverage requirements to align with the change. An initial pneumococcal vaccine may be administered to all Medicare beneficiaries who have never received a pneumococcal vaccine under Medicare Part B. A different, second pneumococcal vaccine may be administered one year after the first vaccine was administered (i.e., 11 full months have passed following the month in which the last pneumococcal vaccine was administered). Please note that the “interval” between the two different pneumococcal vaccines must be 11 or more months for Medicare coverage, not eight weeks or six months as recommended by the ACIP.

The implementation date for the policy change is Feb. 2, effective with dates of service on or after Sep. 19, 2014. Medicare administrative contractors will not search for and adjust any pneumococcal vaccine claims dated on or after Sep. 19, but they may adjust such a claim if the physician brings it to their attention. Additional information can be found at Medicare Learning Network Matters.

– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians