When is it NOT medically necessary to prevent illness? And other Medicare coverage questions for CMS

If you read my post last Wednesday, you now know that the shingles vaccine is covered under the Medicare Part D program. What I neglected to tell you—and what I only recently found out after spending a few hours trying to decipher the doublespeak in the voluminous “Medicare & You” handbook—is that there is a very complicated caveat: Your doctor may need to show that the vaccine is “medically necessary” before your prescription drug plan will cover it.

Yep, there it is, buried on page 93, the only single reference to the shingles vaccine in the entire 148-page “handbook”:

 Except for vaccines covered under Part B, Medicare drug plans must cover all commercially-available vaccines (like the shingles vaccine) when medically necessary to prevent illness. 

The entire sentence is confusing enough, but what exactly does “medically necessary” mean? I wasn’t sure, so I turned to the “Definitions” in Section 8 and read as follows:
Medically Necessary—Services or supplies that are needed for the diagnosis or treatment of your medical condition and meet accepted standards of medical practice.

OK, but the shingles vaccine prevents a very painful medical condition from occurring in the first place, so it precludes the need for a diagnosis or treatment! Does this mean that a preventive vaccine would never fall under the “medically necessary” category, and therefore, never be covered by Part D?

Now I was getting annoyed, so I decided to call Medicare directly and get an answer. 

After weeding through the automated phone system to get an actual person, a very pleasant-sounding gentleman (Jeff Dean) came to the phone. I told him that I was calling on behalf of everyone who has Medicare and is confused about the shingles vaccine. Here is how Jeff explained it to me:

If you are enrolled in a Part D plan you should find out if the plan covers the vaccine. Some plans may require a prior authorization, which means your doctor must contact the drug plan before you can get the vaccine. Your doctor may need to show that the drug is medically necessary for the plan to cover it—in other words, the doctor must determine that you need it because you are at risk or maybe because you had a shingles outbreak before.

A better example, Jeff explained, is the tetanus vaccine: If you just want to get the tetanus vaccine for the sake of prevention, Medicare will not cover it. However, if you step on a nail while gardening and your doctor orders a tetanus vaccine, it will be covered because it is now considered treatment for a condition (an injured foot).

My next step was to find out just who could be “at risk” for shingles. According to numerous clinical sources, including the Mayo Clinic, anyone who has ever had chickenpox is at risk for developing shingles.  Most adults in the United States had chickenpox when they were children, so just about every adult is at risk for shingles! (The vaccine for chicken pox didn’t come to the U.S. until 1995.) The risk also increases with age and is higher in people with compromised immune systems due to diseases such as HIV/AIDS; cancer treatment; or certain medications used to prevent rejection of transplanted organs.

Some important questions for CMS

So now that I have gotten to the bottom of this issue, I have some questions for the Centers for Medicare & Medicaid Services:

1. When is it NOT medically necessary to prevent illness? (Is illness not a medical condition that should be prevented when possible?)
2. Wouldn’t it be better for everyone in the long run—especially seniors—if Medicare and prescription drug plans paid $100 to help prevent this painful condition rather than $500 or more  later on to treat it?
3. Under the Patient Protection and Affordable Care Act, millions of Medicare beneficiaries now have access to many free preventive services, including an annual flu shot, pneumonia vaccine, and hepatitis B vaccine. Since, theoretically, all adults are at risk of getting shingles, shouldn’t this vaccine also be added to the list?

I have many more questions for CMS — such as, When does a book become so big that it can no longer be called a “handbook”? — but I’ll wait until another time to rant more.

Yes, Virginia (and ePatientDave), the shingles vaccine really is covered under Medicare Part D

Last month I posted on a recent study by the U.S. Government Accountability Office (GAO) that shows most Medicare beneficiaries have not received the shingles vaccine, which is covered under the Medicare Part D prescription drug program. The study, which is based on Centers for Disease Control and Prevention (CDC) national survey data for 2009, shows only 11 percent of beneficiaries age 65 and over had received a shingles vaccination.

According to the GAO, some of the barriers affecting beneficiary access to vaccinations are as follows:
• A low percentage of doctors and pharmacies stock the shingles vaccine due to factors such as purchasing costs, storage requirements, and billing challenges
• Physicians recommend shingles vaccinations less often than other vaccines
• Beneficiaries often decline to get vaccinated for shingles
• Prohibitive costs (the cost share for Part D beneficiaries averaged $57 in 2009)
• Challenges with obtaining reimbursement from Part D plans

If I may, GAO, I’d like to throw in my two cents and add to more bullet points:
• Many beneficiaries simply do not know that the shingles vaccine is covered by Part D.
• Many people responsible for providing access to the vaccine (e.g., pharmacists, Part D plan customer service and billing reps, etc.) do not know Part D covers the vaccine!

So how did I come up with this hypothesis? Unlike the GAO, which no doubt spent tons of money reviewing and analyzing data, I simply listened to beneficiaries and their caregivers. I got down to the crux of the matter—and it didn’t cost me a penny.

My “study” began shortly after I posted about the shingles vaccine on December 16, 2011. Several seniors told me they were not aware that the vaccine was covered at all, let alone by Part D.  Roger G. said he never got vaccinated because he couldn’t afford the $200 he thought it was going to cost him. Marge J. contacted me to thank me for alerting her to the fact that Part D covers the vaccine. She said she got a prescription from her doctor, but when she tried to fill it at her CVS pharmacy, the pharmacist turned her away, stating, “Medicare doesn’t cover the shingles vaccine.” 

I then came across this blog by e-Patient Dave, in which he discusses in detail all the hoops he has had to jump through in trying to get the vaccine. Seems that no one Dave spoke to—no one at the hospital, at his insurance company, or even at his wife’s Part D plan!—could help him. (No wonder I always tell people the “D” is for “dummies”.) Some people told him they didn’t know what the vaccine was, some told him it was covered by Part A, some said it was covered by Part B, others said they just didn’t know whether it was covered by A, B, D, or whatever!

So here’s the deal: Medicare Part D DOES cover the singles vaccine, including vaccine administration (the cost for actually sticking the needle in your arm). If you haven’t done so already, ask your doctor about getting vaccinated for shingles. I suggest you might want to refer to the CDC Shingles Vaccination web page if anyone who should know better insists that it is not covered by Medicare Part D or if your plan refuses to reimburse you.

Now, there’s still some more confusing stuff I have to add to this story (hey, it’s Med D, so it has to be complicated!), but I don’t want to overwhelm you so I’ll save that for my next post.

Most Medicare beneficiaries are not getting recommended vaccinations covered under Part D

A study released yesterday by the U.S. Government Accountability Office (GOA) reports that most Medicare beneficiaries have not received routinely recommended vaccinations covered by the Medicare Part D prescription drug program.

According to the Centers for Disease Control and Prevention (CDC) national survey data for 2009, only 11 percent of beneficiaries age 65 and over had received a shingles vaccination and just 53 percent had a tetanus and diphtheria vaccination. In contrast, nearly two-thirds of those over 65 got flu vaccines in 2009 and more than 60 percent were vaccinated against pneumonia, both of which are covered under Medicare Part B.

The GOA reports that these data suggest that beneficiaries received vaccinations prior to enrolling in Medicare or, once enrolled, used other health insurance or paid out of pocket for these vaccinations. However, the agency also points out that a relatively low percentage of doctors and pharmacies stock the shingles vaccine due to factors such as purchasing costs, storage requirements, and challenges with obtaining reimbursement from Part D plans. Since doctors can’t add the vaccine charges to their bills under Part B, seniors have to pay out of pocket (the vaccine can cost around $200) and await reimbursement from their Part D plan or go to pharmacies that can administer the vaccine and bill Medicare directly.

Why is it important to get vaccinated against shingles?

Shingles is a painful, blistering skin rash that affects more than a million Americans each year. Also known as herpes zoster, shingles occurs when the virus that also causes chickenpox—and which can lay dormant in nerve cells for decades—reactivates to cause a painful skin rash. For some people, the intense pain can last for months after the rash clears, which is called postherpetic neuralgia. It can also attack the eyes and permanently damage vision. Even worse, once you get an outbreak, you can continue getting shingles over and over again.

Shingles vaccine reduces risk by more than half

The Food and Drug Administration approved the vaccine against shingles in 2006 after clinical trials on the vaccine revealed that it could, with few side effects, reduce the risk of developing shingles by more than half (and minimize the effects in those patients who do get it). In 2008, a national panel of experts on immunizations at the CDC recommended the vaccine to all adults age 60 and older.

Whether you are a Medicare beneficiary or senior caregiver, it’s important to understand the risks and effects of shingles and to ensure that you or your loved ones are vaccinated. Please help me spread the word that the vaccine is available and covered by Part D plans. And if you haven’t done so already, ask your doctor about getting vaccinated today.