Health Reform & Immunizations National Immunization Conference Atlanta, Georgia Alexandra Stewart [email protected]

Milken Institute, School of Public Health, Department of Health Policy, The George Washington University September 30, 2014

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PURPOSE 1. Understand how the ACA affects access to pneumococcal vaccines (PCV13 & PPSV23) 2. Identify any gaps in coverage or access resulting from changes in ACIP recommendations 3. Discuss implications for consumer access

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ACIP Recommendations for Pneumococcal Polysaccharide Vaccines Before 2012

23 valent vaccine: Ages 65≥ Ages 19-64 with certain conditions: Sickle cell, Asple≥nia, Immunocompromised

Effective 2012

23 valent + PCV13: Adults with immunocompromising conditions

Effective 08/13/14

23 valent + PCV 13 for ages 65≥: 1. All individuals ages 65≥ = Both 23 + 13 2.

No previous or unknown vaccination: 13 FIRST THEN 23 within 6-12 months or next visit after 12 months

ACIP Meeting Results

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Received 23: 13 at least 1 year after most recent 23

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If additional dose of 23 is indicated: 23 + minimum 1 year = 13 + 23 6-12 months later & minimum 5 years after first 23

09/19/14

Recommendation adopted by CDC & published in MMWR

Morbidity and Mortality Weekly Report MMWR / September 19, 2014 / Vol. 63 / No. 37 823 3

ALL PUBLIC & PRIVATE INSURANCE PLANS ARE REQUIRED TO COVER IMMUNIZATIONS

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PRIVATE INSURANCE COVERAGE OF IMMUNIZATIONS State Regulated NonGrandfathered State Exchange Plans State Regulated Grandfathered

1. Must cover ACIP recommended vaccines 2. Must cover newly recommended vaccines: 1 YEAR from CDC adoption of recommendation + NEXT PLAN YEAR

3. No cost-sharing • Plans in effect 3/23/10 may retain current coverage • Not required to cover immunizations • Must continue or improve current coverage policy • No pre-existing condition limitations

• In 2013, larger firms are less likely to have retained grandfathered status compared to small firms (23% to 49%) (Small firms = <5,000 employees) 5

MEDICAID

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MEDICAID – IMMUNIZATION COVERAGE Adults Dual eligible enrollees (ages 65≥ & ages 65≤ with disabilities): 9.6 million in 2010 OPTIONAL

2012 COVERAGE OF PNEUMOCOCCAL VACCINE

States may elect to provide: 1. Adult immunizations recommended by the ACIP & 2. Vaccine administration 48 programs (excluding Florida, Georgia, S. Dakota)

Source: Title IV – Prevention of Chronic Disease and Improving Public Health; Subtitle B – Increasing Access to Clinical Preventive Services; Sec. 4106. Improving access to preventive services for eligible adults in Medicaid; Stewart A, Cox M, Chang K, Vaccination benefits and cost-sharing policy for non-institutionalized adult Medicaid enrollees in the United States, Vaccine Volume 32, Issue 5, Pages 527-638 (23 January 2014). http://www.sciencedirect.com/science/journal/0264410X/32

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MEDICARE

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MEDICARE Part B: VACCINES ELIGIBLE POPULATIONS: Ages 65≥; Ages 65≤ + disability

TOTAL 2012 ENROLLMENT: 54 million 8 million non elderly + disabilities;

2+ million live in LTCFs

Vaccines directly related to the treatment of an injury or direct exposure to a disease or condition 1981 Pneumococcal (once per lifetime) 1984 Hepatitis B (risk-based) 1993 Influenza (annually) 1993 Administration Fee (Regional differences) Source: Social Security Act 1861 (s)(10)(A)

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MEDICARE PART D: Prescription Drug Benefit VOLUNTARY ENROLLMENT ESTABLISHED 2006 CMS

37 million enrollees (2014)

Must cover all commercially available vaccines not covered under B COVERAGE STANDARD: Reasonable + necessary to prevent illness ENROLLEE COST-SHARING POLICY: Any co-pays should apply to both vaccine + administration Plans should not charge separate co-pays for vaccine & it’s administration

Part D PLANS

Each plan determines: Coverage, Deductible, Cost-sharing, Provider reimbursement

ENROLLEES

Should: Review each plan to determine coverage for new vaccines, that may not appear in Plan’s formulary, even though the vaccine is covered May be required to: 1) to pay upfront 2) submit claim for reimbursement up to Plan’s allowable charge 3) Pay difference if Provider charges more than Plan will reimburse

Source: Vaccine Payments under Medicare Part D, Medicare Learning Network, June 2013

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LTCFs & CONDITIONS OF PARTICIPATION COVERED ENTITIES: Skilled Nursing & Nursing Facilities (LTCFs) 38,000 (2012) ELIGIBLE POPULATIONS: over 2 million Residents of LTCFs CMS

Effective 2005 LTCFs must provide or obtain immunizations for residents (TIMING & FREQUENCY UNCLEAR) COVERAGE STANDARD: ACIP or the Committee on the Control of Infectious Diseases of the American Academy of Pediatrics FAILURE TO COMPLY: Ineligible for reimbursement for Medicare/Medicaid beneficiaries

LTCFs

Must: • Assess residents’ vaccination status • Provide education regarding health status • Provide opportunity to opt out • Provide or obtain immunizations • Adopt ACIP standard

RESIDENTS May: Accept or decline vaccination Source: 42 CFR Ch. IV (10-1-11 Edition) §483.460 Condition of participation: Health care services

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IMPLICATIONS FOR CONSUMER ACCESS Private Insurance Coverage: • Many plans will adopt coverage before they are required

Medicaid: • Coverage remains optional • Most programs will cover over time with broad variation based on cost • CMS could issue a Medicaid Directors Letter to encourage coverage

Medicare: • Part B: Coverage could be added to Part B (minimizes financial impact to consumers) • Part D plans: Likely to cover with consumer cost-sharing & administrative barriers

• LTCFs: Residents may have immediate & ensured access based on COPs 12