AVAC Sends CMS Recommendations Around Improving Adult Immunization

AVAC wrote a letter offering recommendations for CMS that will help to strengthen, enhance, and expand access and utilization of essential immunization services during and beyond the COVID-19 pandemic.


To:  Seema Verma, Administrator for the Center for Medicare at the Centers for Medicare and Medicaid Services

From: Adult Vaccine Access Coalition (Abby Bownas / Lisa Foster, AVAC Managers)

CC: Brady Brookes; Demetrios Kouzoukas; Kimberly Brandt; and Jeffrey Kelman

Date: 7/29/2020

Re: Recommendations to CMS around improving Adult Immunizations

Incentivize beneficiary uptake of recommended routine immunizations through first dollar coverage of vaccines under Medicare Part D and Medicaid;On behalf of members of the Adult Vaccine Access Coalition (AVAC), we write to offer several recommendations for the Centers for Medicare and Medicaid Services (CMS) that will help to strengthen, enhance, and expand access and utilization of essential immunization services during and beyond the COVID-19 pandemic, including:

  • Alleviate provider burdens to offering immunizations through enhanced and timely reimbursement for vaccine administration;
  • Expand opportunities and give health care providers greater flexibility to provide necessary counseling and education to patients and caregivers;
  • Develop an immunization communication & outreach

About AVAC

AVAC consists of over 55 organizational leaders in health and public health that are committed to addressing the range of barriers to adult immunization and to raising awareness of the importance of adult immunization. AVAC works towards common legislative and regulatory solutions that will strengthen and enhance access to adult immunization across the health care system. Our priorities and objectives are driven by a consensus process with the goal of enabling the range of  stakeholders to have a voice in the effort to improve access and utilization of adult immunizations. To learn more about the work of AVAC visit www.adultvaccinesnow.org.

Incentivize beneficiary uptake of recommended routine immunizations through first dollar coverage of vaccines under Medicare Part D and Medicaid. 

Eliminate Cost Sharing Under Part D

Immunization coverage for Medicare beneficiaries is segmented between Medicare Part  B,  which covers vaccinations against influenza, pneumococcal  and  hepatitis  B  for  at-risk  patients  and Medicare Part D, which covers all other commercially available vaccines when deemed medically necessary to prevent illness. While beneficiaries receive Part B-covered vaccines with no cost sharing, they often encounter copays or cost sharing requirements for Part D vaccines. Studies have shown that the cost sharing requirements on Part D vaccines discourage immunization uptake among older people, people with disabilities, and chronically ill populations.1

We encourage CMS to work with Part D sponsors to offer either a $0 vaccine tier, or to place vaccines on a formulary tier with low cost sharing. Now is the time to empower Medicare beneficiaries with the tools they need to stay healthy during the pandemic and beyond. Immunizations are one of the most effective and efficient forms of prevention that we know save lives and billions in avoidable health care costs.

Provide Uniform Access in Medicaid

We also encourage CMS to issue guidance to states to provide uniform access to vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) for all Medicaid populations with no cost sharing. Low-income and minority Medicaid and Medicaid Managed Care beneficiaries have unequal access to vaccines compared to those with commercial insurance coverage. Medicaid enrollees also experience higher rates of chronic conditions, such as heart and lung diseases, and diabetes, which increase their risk of serious and adverse health consequences from vaccine preventable illness.

Alleviate provider burdens to offering immunizations through enhanced and timely reimbursement for vaccine administration

Increasing Reimbursement for G Codes

Ensuring that clinicians are properly reimbursed is another key to fostering a sustained environment for high-value immunizations. Inadequate reimbursement for vaccination administration discourages providers from proactively offering immunizations, and results in missed immunization opportunities and declines in immunization rates.2 Administering routine or pandemic vaccines comes with a number of important responsibilities for providers, including staff training, ordering and tracking vaccine inventory and ancillary supplies for vaccine administration, proper handling, storage and reporting for each vaccine administered, as well as counseling and educating patients and caregivers. A new vaccine for COVID-19 will require all of these activities on a potentially unprecedented scale all while having to implement new safety measures while vaccinating.

In order to incentivize primary care practices to start immunizing again, CMS should increase reimbursement for G codes (including G0008, G0009, G0010) for the 2020 flu vaccine season. Due to COVID-19, there has been a drop in routine immunizations across the life course.3 While practices are starting to rebound in terms of patient visits, they are not rebounding in immunization delivery. There is a concern for the upcoming influenza season that if people served by Medicare continue using the telehealth services and mail order pharmacy that were expanded to protect them from COVID-19, there will be decreases in the immunization opportunities for patients most vulnerable to vaccine preventable illness.

With the flu vaccine season starting in about 2 months, better payment incentives can be a noteworthy solution in order to drive provider behavior and thereby reduce the risk of patients missing flu vaccine in a year when it may never be more important. Likewise, pneumococcal numbers are down significantly, leaving people over the age of 65 at risk for secondary bacterial pneumonia with flu or a COVID primary infection. Reimbursement for G codes have been reduced over several years and the unintended consequences are now visible. Restoring payment for G codes to 2017 levels may drive better vaccine delivery and reduce the burden of vaccine preventable diseases across the population.

DeCouple Practice Expenses for Vaccine Administration from Therapeutic Injection

AVAC is grateful that the Administration acted to stop a proposed 15 percent reduction in payment for CPT codes for vaccine administration (90471-90474) in the CY2020 physician fee schedule (PFS) rule, which stated, “We recognize that it is in the public interest to ensure appropriate payments to physicians and other practitioners for provision of the immunization administration services that are used to deliver vaccines and plan to review the valuations for these services to ensure appropriate payment.” We appreciated the intervention of the HAPG when AVAC brought to their attention that some MACs had in fact implemented the reduction in vaccine administration codes from the proposed rule. We urge CMS to ensure that all MACs are consistently applying the higher reimbursement rate for 2020 in accordance with the final rule and to retrospectively reimburse providers who may have received a lower rate as a result of this error.

Looking to the CY2021 proposed PFS rule, we strongly urge CMS to decouple the practice expense   RVU for vaccine administration from therapeutic injection (96372) and instead utilize the RUC- recommended direct PE inputs. These direct PE inputs were reviewed in October 2009 for practice expense RVUs for CPT immunization administration codes 90471, 90473, and 90460 and would provide relief from automatic reductions in vaccine administration practice expense RVUs at a time when the costs associated with maintaining a vaccine program are rising.

Require Medicaid managed care plans to offer formulary adoption for all U.S. influenza vaccines.

With the overwhelming number of influenza doses purchased by providers and the Centers for Disease Control and Prevention (CDC), it is critical that providers are able to bill and receive reimbursement for the vaccine product as well as the administration fee for Medicaid eligible patients. We urge CMS to direct State Medicaid fee-for-service and Medicaid managed care plans to adopt all CPT codes for influenza vaccines on all plan formularies to assure reimbursement for the product and the administration service. This guidance should include the following influenza CPT codes: (ccIIV4) 90674 and 90756; (RIV4) 90682; (LAIV4) 90672; (IIV4) 90685 – 90688.

Expand opportunities and give health care providers greater flexibility to provide necessary counseling and education to patients and caregivers;

E/M Coding for Telehealth that Considers Immunization Assessments

We appreciate CMS recent ruling on E/M coding that will enable primary care providers to conduct patient immunization status assessments and counseling, particularly for complex patients with    chronic conditions. We encourage CMS to consider allowing the use and billing for telehealth services to do E/M for vaccines remotely.

Enhanced Reimbursement for Immunization During the Public Health Emergency

We urge CMS to announce an enhanced fee for vaccine administration to ensure providers are able to offer immunization services to Medicare beneficiaries in environments that are safe for all. Provider offices are expanding outreach efforts to counsel on the need for influenza vaccine during the pandemic and the practices that the providers are instituting to make patients feel the office is a  safe place to seek immunization. These efforts are critical to maintain the immunization rates achieved in previous years. Additionally, providers are working to include innovative options such as drive-by or drive-through vaccinations or offering vaccinations in a patient’s home. We also encourage CMS to extend this enhanced fee to immunizers who roster bill for vaccines. In-office and alternative immunization approaches will come with added costs, such as increased staff costs for patient scheduling and communication, reconfiguration of practice sites to accommodate immunization-only hours and immunization-only areas, increased reliance of mobile technology to record vaccine information in the patient medical record and with the public health immunization program, and additional equipment will be necessary for proper storage and handling of vaccine supply being administered in home or community-based settings.

Provide an enhanced Medicaid FMAP for vaccine counseling and administration.

Providing an enhanced payment for providers who care for underserved populations will also enable them to improve and expand immunization programs within their practices through the adoption of interoperable and bidirectional immunization reporting capabilities. These additional resources will be essential to ensure that providers are able to effectively offer this lifesaving preventive service through this critical safety net program. We further recommend that CMS issue guidance to state Medicaid plans targeted at eliminating racial, socio economic and geographic disparities around vaccination.

Develop an immunization communication & outreach strategy.

Beneficiary Outreach

Due in large part to the magnitude of this effort, CMS should engage in a timely, comprehensive, and equitable vaccination campaign. Such a campaign should be broad based and focused on reminding patients of the importance of asking providers about all recommended vaccines for Medicare, including Part B vaccines (influenza, pneumonia, and Hepatitis), as well as Part D vaccines (tetanus, diphtheria, pertussis, zoster (shingles)). Activities could include:

  • Updates to various agency websites, including gov, Centers for Disease Control and Prevention flu and pneumococcal vaccine-specific websites, the Social Security Administration, Medicare Administrative Contractors (MACs);
  • Social Media Campaign for beneficiaries and loved ones;
  • Email messages from CMS or the Social Security Administration directly to Medicare beneficiaries;
  • Special notices about these new programs and their importance via US Mail;
  • Special notices available at places frequented by Medicare beneficiaries even during the COVID-19 pandemic, such as grocery stores and pharmacies;
  • Colorful informational inserts in Medicare Summary Notices that Medicare beneficiaries routinely receive from CMS; and
  • Public Service Announcements, including television commercials by personalities widely recognized by senior

Provider Outreach

A strategy should also engage healthcare professionals (HCPs) urging that providers make a strong recommendation to vaccinate for all ACIP recommended immunizations. In addition to the ability to leverage direct lines of communication to their patients, HCPs are viewed as trusted sources regarding how beneficiaries may safely receive preventative care during the COVID-19 national outbreak. Outreach to HCPs should encourage providers to raise the awareness of their patients regarding the need to receive all ACIP recommended vaccinations and the alternative vaccination options that may be available to them. Providing these communications through HCPs will give older adults and their caregivers the confidence to receive their recommended vaccinations and feel safe in receiving vaccinations in their chosen location this year and moving forward. Such engagement might include:

  • MLN Matters notifications encouraging providers to forward specific communications regarding available alternative vaccination options to their patients; and
  • Introduction by CMS of a Merit-based Incentive Payment System (“MIPS”) practice improvement measure based on enhanced provider communication to patients regarding the special need for vaccine awareness, including available alternative vaccination

As part of all of CMS educational efforts, the Center should proactively work to address disparities in vaccine coverage and help build confidence in and demand for immunization services. This should include the development of culturally-appropriate immunization materials for Medicaid providers.

Again, thank you for the opportunity to share our perspective with respect to issues that are having an acute impact on Medicare and Medicaid Immunization issues. Now more than ever before we must effectively utilize the proven health care interventions of immunizations to help older adults and individuals with chronic conditions to remain healthy. Members of our coalition would be interested in setting up time to further discuss our recommendations with you at your earliest convenience. Abby Bownas, AVAC Manager, will follow up with your staff to schedule a discussion.


  1. http://go.avalere.com/acton/attachment/12909/f-0297/1/-/-/-/-/20160217_Medicare%20Vaccines%20Coverage%20Paper.pdf; http://www.jmcp.org/doi/10.18553/jmcp.2015.21.s4.1; http://www.jmcp.org/doi/pdf/10.18553/jmcp.2016.22.4.S1
  2. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4594851/
  3. https://www.cdc.gov/mmwr/volumes/69/wr/mm6919e2.htm?s_cid=mm6919e2_w