Findings

Congress makes the following findings: (1)Herpes zoster, also known as shingles, is caused by the reactivation of the varicella-zoster virus that causes chickenpox in childhood. The virus can reactivate later in life, resulting in a painful, itchy rash that can persist for weeks, months, or years. Not only does the risk of herpes zoster itself increase with age, but, among individuals who experience herpes zoster, older individuals are much more likely to experience postherpetic neuralgia non-pain complications, hospitalizations, and interference with activities of daily living, such as eating, dressing, and bathing. (2)Postherpetic neuralgia, a complication of shingles, occurs rarely among individuals under age 40 but can occur in up to 1/3 of untreated individuals age 60 and older. (3)The Food and Drug Administration approved the herpes zoster vaccine for individuals age 50 and older. The Advisory Committee on Immunization Practices presently recommends the herpes zoster vaccine for all individuals age 60 and older. (4)The Healthy People 2020 target baseline for the herpes zoster vaccine is 30 percent coverage for individuals age 60 and over. This benchmark is unfortunately low compared to that of other adult vaccines such as influenza (70 percent) and pneumococcal disease (60 percent). Even at such a low target, the coverage rate is not being met. The Centers for Disease Control and Prevention reported that in 2014, only 28 percent of adults age 60 and older reported receiving the herpes zoster vaccine. (5)According to the 2014 National Health Interview Survey of the Centers for Disease Control and Prevention, vaccination rates for adults are 20 percent for Tetanus, Diphtheria, and Pertussis, 28 percent for shingles, 24 percent for Hepatitis B, and 61 percent for pneumonia. There are also disparities across adult vaccination rates. Adult immunization rates are generally lower among Hispanics, African Americans, and Asians. (6)Medicare coverage for the herpes zoster vaccine under the Prescription Drug Program under part D of title XVIII of the Social Security Act has resulted in many barriers to optimal and consistent uptake to prevent shingles and its costly and painful complications. (7)Lack of awareness and logistical and financial challenges are the most often cited reasons for Medicare beneficiaries not being immunized against the varicella-zoster virus. (8)Herpes zoster is estimated to account for more than 87,000 emergency room visits and 28,000 inpatient admissions each year. Average costs across the episode of care were $1,835 and $14,428 per patient in the outpatient and inpatient settings, respectively.

Provision of information regarding vaccines for seniors as part of Medicare & You handbook and coverage of the shingles vaccine under Medicare part D

(a)

Provision of information regarding vaccines for seniors as part of Medicare & You handbook

(1)

In general

Section 1804 of the Social Security Act (42 U.S.C. 1395b–2) is amended— (A)in subsection (a)(1), by inserting , including information with respect to coverage of vaccines for seniors described in subsection (d) before the comma at the end; and (B)by adding at the end the following new subsection:

(d)The notice provided under subsection (a) shall include information with respect to vaccines for seniors, including information with respect to coverage of the shingles vaccine under part D for individuals enrolled in a prescription drug plan under such part.

(2)

Effective date

The amendments made by this subsection shall apply to notices distributed prior to each Medicare open enrollment period beginning after the date of implementation of section 1860D–2(b)(8), as added by subsection (b)(2). (b)

Coverage of the shingles vaccine under Medicare part D

(1)

Provision of educational materials regarding the availability of ACIP-recommended herpes vaccine with no cost sharing

Section 1860D–4(a)(1)(B) of the Social Security Act (42 U.S.C. 1395w–104(a)(1)(B)) is amended by adding at the end the following new clause:

(vi)For plan years beginning on or after January 1 of the first year beginning more than 60 days after the date of the enactment of this clause, information regarding access to the shingles vaccine with no cost sharing under the plan.

(2)

Ensuring treatment of cost sharing is consistent with treatment of vaccines under Medicare part B

Section 1860D–2(b) of the Social Security Act (42 U.S.C. 1395w–102(b)) is amended— (A)in paragraph (1)(A), by striking The coverage and inserting Subject to paragraph (8), the coverage; (B)in paragraph (2)(A), by striking and (D) and inserting and (D) and paragraph (8); (C)in paragraph (3)(A), by striking and (4) and inserting (4), and (8); (D)in paragraph (4)(A)(i), by striking The coverage and inserting Subject to paragraph (8), the coverage; and (E)by adding at the end the following new paragraph:

(8)

Treatment of cost sharing for shingles vaccine consistent with treatment of vaccines under part B

For plan years beginning on or after January 1 of the first year beginning more than 60 days after the date of the enactment of this paragraph: (A)

No application of deductible

The deductible under paragraph (1) shall not apply with respect to the shingles vaccine. (B)

No application of coinsurance

There shall be no coinsurance under paragraph (2) with respect to the shingles vaccine. (C)

No application of initial coverage limit

The initial coverage limit under paragraph (3) shall not apply with respect to the shingles vaccine. (D)

No cost sharing above annual out-of-pocket threshold

There shall be no cost sharing under paragraph (4) with respect to the shingles vaccine.

(3)

Conforming amendments to cost sharing for low-income individuals

Section 1860D–14(a) of the Social Security Act (42 U.S.C. 1395w–114(a)) is amended— (A)in paragraph (1)(D), in each of clauses (ii) and (iii), by striking In the case and inserting Subject to paragraph (6), in the case; (B)in paragraph (2)— (i)in subparagraph (D), by striking The substitution and inserting Subject to paragraph (6), the substitution; and (ii)in subparagraph (E), by striking subsection (c) and inserting paragraph (6) and subsection (c); and (C)by adding at the end the following new paragraph:

(6)

No application of cost sharing for shingles vaccine

Consistent with section 1860D–2(b)(8), for plan years beginning on or after January 1 of the first year beginning more than 60 days after the date of the enactment of this paragraph, there shall be no cost sharing under this section with respect to the shingles vaccine.

(c)

Study and report

(1)

Study

The Secretary of Health and Human Services (referred to in this subsection as the Secretary), acting through the Director of the Centers for Disease Control and Prevention, in collaboration with the Administrator of the Centers for Medicare & Medicaid Services, shall conduct a study on the uptake of vaccines, including the herpes zoster vaccine and the tetanus, diphtheria, and pertussis vaccine, and anticipated vaccines against such diseases as respiratory syncytial virus, clostridium difficile, and others. Such study shall include an analysis of ways to— (A)increase the baseline target rate of coverage for currently recommended vaccines, such as herpes zoster vaccine coverage in the Healthy People 2030 goals; (B)ensure that the baseline target focuses on reducing racial and socio-economic disparities in the vaccine coverage rates for all adult vaccines, including the herpes zoster vaccine; and (C)help facilitate vaccination for Medicare beneficiaries for vaccines recommended by the Centers for Disease Control and Prevention both currently and in the future, by developing and evaluating a specific set of actions that will address physician and health care provider administrative challenges, such as difficulty verifying beneficiary coverage and complexity of physician office billing of vaccines covered under Medicare part D, that impact access for beneficiaries. (2)

Report

Not later than 2 years after the date of enactment of this Act, the Secretary shall submit to Congress a report containing the results of the study under paragraph (1), together with recommendations for such legislation and administrative action as the Secretary determines appropriate.