Medicare Coverage Change Related to New Pneumococcal Vaccine Recommendations

Karen Morris and Nancy Leveille in Clinical & Quality

We have received the following information from DOH, effective date 2/1/15:

On September 19, 2014 the Centers for Disease Control and Prevention (CDC) published new ACIP (Advisory Committee on Immunization Practices) recommendations for pneumococcal vaccination of adults. Adults aged 65 years and older are now recommended to be vaccinated with the pneumococcal conjugate vaccine (PCV13, Prevnar-13 ®) first and then be vaccinated with the pneumococcal polysaccharide vaccine (PPSV23, Pneumovax®23) 6-12 months later. The two vaccines should not be co-administered, and the minimum acceptable interval between the PCV13 and PPSV23 is 8 weeks.  Adults 65 years of age or older who have previously received PPSV23 should receive the PCV 13 at least 1 year after their most recent dose of PPSV23.  The full ACIP statement is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6337a4.htm  Sequential administration and recommended intervals for PCV13 and PPSV23 are noted on this site.  http://www.cdc.gov/vaccines/vpd-vac/pneumo/vac-PCV13-adults.htm is another link with excellent information explaining the recommendations and has a Q and A section at the end of the recommendations.

We were informed on 1/7/14 CMS is updating the Medicare coverage requirements to align with the updated ACIP recommendations for Coverage of Pneumococcal Vaccinations.  The implementation for this change is February 2, 2015. Previously, Medicare would cover only one dose of pneumococcal vaccine, either PCV13 or PPSV23 but not both, for adults 65 years of age or older.   A different, second pneumococcal vaccine may be administered 1 year after the first vaccine was administered. Billing information is outlined in the Medicare Claims Processing Manual; Transmittal 3159.  The following link contains CMS modifications for the coverage: http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/2014-Transmittals-Items/R3159CP.html

Healthcare providers should discuss with previously vaccinated patients, the risks and benefits of administering PCV13 vaccine.  While the NYS regulation has not changed, the standard of care or best practice and the Medicare Coverage for pneumococcal vaccinations has changed.  It is important for our long term care facilities to have this discussion with their medical directors and prepare to implement these best practices related to pneumococcal vaccine (develop policy/procedure and educate staff).

NYSHFA CONTACTS:

Karen Morris, RN, MS
Director, Clinical & Quality Services
518-462-4800 x15

Nancy Leveille, RN, MS
Sr. Director, Member Operational Support
518-462-4800 x20