Expanded Medicare Coverage for Vaccines Could Reduce Preventable Illnesses


Study found no standalone Medicare Part D plans covered vaccinations without out-of-pocket payments.

If Medicare expands and covers a broader scope of vaccinations, it could encourage more Medicare insurers to cover vaccines, a recent study found.

An analysis by Avalere Health that covered trends from 2011 to 2016 found Medicare enrollees still have limited access to 10 recommended vaccines without copayments, despite policymakers encouraging broader vaccination rates.

The results of the analysis performed by Avalere showed that about 12% of enrollees in Medicare Advantage Prescription Drug (MA-PD) plans had access to the vaccinations in 2016 without having to pay copays. This is up from less than 5% in 2011.

It was found that no standalone Part D plans (PDPs) covered the vaccinations without out-of-pocket payments during the 6 years of the analysis. Some of these vaccinations were for diseases like tetanus, hepatitis A, and hepatitis B.

“Rates of vaccine-preventable illnesses are particularly high among older adults,” said Senior Vice President of Avalere, Caroline Pearson. “While most private insurance plans are now required to cover recommended vaccines at no cost to the patient, very few Medicare beneficiaries enjoy this same level of coverage.”

Several steps have been taken to expand vaccination rates including:

  • Office of Disease Prevention and Health Promotion’s Healthy People 2020, which had a goal of increasing the immunization rates and reduced cases of disease
  • Seventeen issued recommendations on vaccine-preventable conditions from the Centers for Disease Control and Prevention (CDC) to help guide health care providers The ACA required most health care plans in the commercial market to cover vaccinations at no cost to patients Medicare encouraged Part D plans to adopt Vaccine Tiers with low cost sharing amounts, in order to promote greater access to vaccinations for beneficiaries.

There were approximately 24 million beneficiaries who were enrolled in standalone PDPs and 13.5 million in non-employer MA-PDs in 2015, the study found.

Also in 2015, there was found to be a significant difference between the types of cost sharing that MA-PD plans used compared to standalone PDPs. For enrollees in the MA-PD plans, about 80% to 90% had a fixed dollar co-payment for the vaccines, compared to 37% to 72% of with standalone PDPs.

“Medicare has an opportunity to encourage broader use of these vaccines through expanded coverage,” said President of Avalere, Dan Mendelson. “Options like including vaccine access in the existing star ratings program may encourage more Medicare insurers to cover vaccines at no cost to the patient.”

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