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Immunizations

Approximately 50,000 adults die each year from vaccine-preventable diseases in the U.S.  Pneumonia and influenza are the fifth leading cause of death in older adults in the U.S.  According to the Centers for Disease Control and Prevention (CDC), 1.25 million people are infected with the hepatitis B virus, which attacks the liver and can cause liver cancer, liver failure, and death.  

This section provides information and resources related to the coverage, billing, delivery, and promotion of seasonal influenza, pneumococcal, and hepatitis B vaccinations. Medicare, Medicaid and CHIP (for children) cover both the costs of these vaccines and their administration by recognized providers. The following sections address influenza and pneumococcal vaccinations together because of the similarities in their coverage and billing policies. Hepatitis B vaccination is addressed separately.

This page provides general facts about adult immunization and links to other resources. These resources include a immunization poster which can be downloaded and used in efforts to promote adult immunization.

General Facts:

  • Influenza, also called the "flu," is a contagious respiratory illness caused by influenza viruses. There are over 200,000 hospitalizations from influenza on average every year. An average of 36,000 Americans die annually due to influenza and its complications – most are people 65 years of age and over. The best way to prevent the flu is to get vaccinated each year during the fall season. Because flu viruses change from year to year, it is important to get a flu shot each year. Medicare pays for the influenza immunization or "flu vaccine." The links below provide general information related to influenza vaccinations.
  • Pneumococcal pneumonia is the most common type of bacterial pneumonia. There are over 40,000 cases of invasive pneumococcal disease in the U.S. and approximately one-third of these cases occur in people 65 and older. Over half of the more than 5,000 annual deaths from invasive pneumococcal disease occur in persons 65 years of age and older. Medicare covers one pneumococcal vaccination for all Medicare beneficiaries. One vaccine at age 65 generally provides coverage for a lifetime, but for some high risk persons, a booster vaccine is needed. Medicare will also cover a booster vaccine for high risk persons if 5 years have passed since their last vaccination. The links below provide general information related to pneumococcal vaccinations.
  • Hepatitis B virus can cause serious liver disease, including cirrhosis, liver cancer, liver failure, and death. The virus is found in the blood and body fluids of infected people and can be spread through sexual contact or the sharing of needles. The hepatitis B vaccination can protect high risk persons, such as people with renal disease or hemophilia, from contracting the disease. The vaccine is delivered in a series of 3 shots. Medicare pays for hepatitis B vaccination for people considered to be at high risk for the disease.

What Medicare covers?

  • Influenza Immunizations: Medicare began covering annual influenza immunizations in 1993 for all Medicare beneficiaries. Medicare covers both the costs of the vaccine and its administration by recognized providers. There is no coinsurance or co-payment applied to this benefit, and a beneficiary does not have to meet his or her deductible to receive this benefit.
  • Pneumococcal Polysaccharide Vaccinations: Medicare began covering pneumococcal polysaccharide vaccinations in 1981. Medicare provides coverage for 1 pneumococcal polysaccharide vaccine for all beneficiaries. One vaccine at age 65 generally provides coverage for a lifetime, but for some high risk persons, a booster vaccine is needed. Medicare will also cover a booster vaccine for high risk persons if 5 years have passed since the last vaccination. Medicare covers both the costs of the vaccine and its administration by recognized providers. There is no coinsurance or co-payment applied to this benefit, and a beneficiary does not have to meet his or her deductible to receive this benefit.
  • Hepatitis B Vaccinations: Medicare began covering hepatitis B vaccinations in 1984. Persons at high or intermediate risk, such as people with renal disease or hemophilia, homosexual men, and clients of institutions for the mentally handicapped are among those who are eligible to receive this benefit. Medicare covers both the costs of the vaccine and its administration by recognized providers. The coinsurance or co-payment applies after the yearly deductible has been met.

What Medicaid Covers?

  • Medicaid and CHIP cover influenza  vaccine for children that are beneficiaries as well as all other recommended vaccines.

Other Helpful Information:

  • Despite Medicare coverage for influenza, pneumococcal, and hepatitis B vaccinations, the use of these benefits is not optimal. In 2006, 64% of people 65 and older reported receiving a flu shot in the past 12 months; however, only 46% of non –Hispanic blacks and 45% of Hispanics reported receiving a flu shot, compared with 67% of non-Hispanic whites. While 57% reported having ever received a pneumonia vaccination, only 36% of non-Hispanic blacks and 33% of Hispanics reported ever receiving a pneumonia vaccination, compared with 62% of non-Hispanic whites.
  • CMS has a long history of working with the CDC and other outside organizations, including the National Coalition on Adult Immunization, to promote influenza and pneumococcal immunizations to Medicare beneficiaries. CMS has implemented quality improvement efforts to improve rates in a variety of health care settings, including hospitals and nursing homes. CMS has also initiated changes in payment rates, billing processes, and the conditions of participation for nursing homes and home health agencies to facilitate the delivery of influenza and pneumococcal immunizations to Medicare beneficiaries.
  • The 2011-2012Immunizers' Question & Answer Guide to Medicare and Medicaid Coverage of Influenza and Pneumococcal Vaccinations addresses immunizers' commonly asked questions about the administration of seasonal influenza and pneumococcal vaccines to Medicare and Medicaid patients.

Current Rates for Seasonal Influenza 

Vaccine rates can be accessed by going to http://www.cms.gov/McrPartBDrugAvgSalesPrice/10_VaccinesPricing.asp#TopOfPage or the Link Inside CMS, "Seasonal Influenza Vaccine Rates." To determine current administration rates, go to http://cms.gov/apps/physician-fee-schedule/ or the Link Inside CMS, "Administrative Rates Search."