January 07, 2015


Summit Buzz – Supplement, January 07, 2015


CMS Modifies Medicare Payment Regulations for Second Dose of Pneumococcal Vaccine

Good news from the Centers for Medicare & Medicaid Services (CMS) regarding payment for a second dose of pneumococcal vaccine via Medicare! On December 31, 2014, CMS issued Change Request (CR) 9051, Modifications to Medicare Part B Coverage of Pneumococcal Vaccinations, to align Medicare pneumococcal vaccine coverage requirements with the Advisory Committee on Immunization Practices (ACIP) recommendations. The full transmittal is available online, and the pertinent information is excerpted below. In addition, an official MLN Matters article is available to provide supplemental information about this change.

The Business Requirements section of the guidance states:

EFFECTIVE DATE: September 19, 2014
*Unless otherwise specified, the effective date is the date of service.



  • Background: Medicare Part B covers certain vaccinations including pneumococcal vaccines. Generally, pneumococcal vaccine was covered once in a beneficiary’s lifetime, with revaccinations covered for those at highest risk if 5 years have passed since the last vaccination, or if the beneficiary’s vaccination history was unknownThe ACIP recently updated its guidelines regarding pneumococcal vaccines. The ACIP recommends administration of two different pneumococcal vaccinations.
  • Policy: CMS is updating the Medicare coverage requirements to align with the updated ACIP recommendations. 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 1 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, not 8 weeks or 6 months as in the ACIP recommendations. We do not know the considerations that were in the CMS process, but it is possible that this was the most direct/expeditious way to execute the payment for the second dose.

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