Press release



Nursing homes serving Medicare and Medicaid patients will have to provide immunizations against influenza and pneumococcal disease to all residents if they want to continue in the programs, according to a final rule published by CMS in today’s Federal Register.


As a condition of participation in the two programs, nursing homes will be required to ensure that residents received the immunizations.  The resident or the resident’s family can refuse the shots.  Residents who cannot receive the vaccines for medical reasons are exempt. Under the final rule, nursing homes will also be required to educate the resident and/or the resident’s family about the advantages and possible disadvantages of receiving the vaccines.


About two million Americans, most age 65 years or older, live in long-term care facilities.  People aged 65 years and older account for more than 90 percent of influenza-related deaths in the United States and elderly nursing home residents are particularly vulnerable to influenza-related complications. In addition, the elderly are more likely than younger individuals to die from pneumonia.


In light of these statistics and in line with the agency’s Nursing Home Quality Initiative, CMS received input from the Centers for Disease Control and Prevention (CDC) and two of the nation’s largest nursing home industry trade groups, the American Association of Homes and Services for the Aging and the American Health Care Association, in developing the proposed rule. 


“Improving immunization is a key element of our quality improvement strategy—a strategy that is focused on preventing illnesses and complications in the first place,” said Mark B. McClellan, M.D., Ph.D., administrator of CMS.  “The outstanding commitment of the nursing home industry, caregivers and other stakeholders makes clear that this commitment to better quality through more effective immunization is shared and achievable.


“As a physician, I know the impact that influenza and pneumococcal infections can have on the elderly, particularly those in nursing homes,” he added. “Greater use of flu shots and pneumococcal vaccine in nursing homes is a proven approach to better health and fewer costly complications for one of our most vulnerable groups of beneficiaries.”


In its collaborative effort to improve quality of care, CMS is also encouraging nursing homes to provide influenza vaccine to their healthcare workers.  Although the vaccine for these workers will not be required in the final regulation, immunizing nursing home workers has been shown to reduce mortality rates among residents of long-term care facilities.  Research from last year’s flu season revealed that only 36 percent of all healthcare workers were vaccinated against the illness.


A 1999 national nursing home survey showed that 65 percent of residents had documented influenza shots and only 38 percent had been inoculated against bacterial pneumonia.  A goal of this proposed rule is to attain a target rate of 90 percent for both vaccinations.  As an added incentive to increase immunization rates, in January, CMS increased the average Medicare payment rate for administering each shot from $8 to $18, in addition to a separate payment for the cost of the vaccine.  Medicaid payment rates are set independently by each state.


As a Medicare condition of participation, the rule requires that long-term care facilities ensure that each resident is:


  • offered influenza immunization annually;
  • immunized against influenza unless medically contraindicated or when the resident or the resident’s legal representative refuses immunization;
  • offered pneumococcal immunization once if there is no history of immunization; and
  • immunized against pneumococcal disease unless medically contraindicated or when the resident or the resident’s legal representative refuses immunization.


In the case of a vaccine shortage as declared by CDC, state survey agencies would have the discretion not cite facilities for being out‑of­‑compliance with this requirement.


“Vaccines against these diseases are effective in preventing hospitalizations and death,” said Dr. McClellan. “However, many at-risk people are not getting the vaccines they need.  This initiative will be critical to maintaining high-quality care in the nation’s long-term care facilities.”