DEPARTMENT OF HEALTH & HUMAN 
SERVICES Health Care Financing Administration  
Center for Medicaid and State Operations 7500 Security Boulevard Baltimore, MD 21244-1850  
November 22, 2000  
Dear State Medicaid Director:  
The Health Care Financing Administration (HCFA) and the Centers for Disease Control and 
Prevention (CDC) are coordinating efforts to promote influenza and pneumococcal vaccines to 
adult residents of nursing facilities. The goal is to immunize at least 90 percent of the 
institutionalized population to meet the Healthy People 2010 objectives through a national quality 
improvement program. Your cooperation is essential to reach this goal.  
We would like you to help us promote immunization standing orders programs to ensure that all 
nursing facility residents are assessed for and offered influenza and pneumococcal vaccinations. 
Influenza and pneumonia combined represent the fifth leading cause of death in the elderly. 
Influenza epidemics alone, occurring nearly every year, are responsible for approximately 20,000 
deaths per year in the United States. To help accomplish our goal, we ask that you communicate 
your support in a letter to all nursing facilities in your State and review your coverage of 
immunizations for adults. The details of those requests are discussed below. A fact sheet on 
influenza and pneumococcal disease is enclosed for your  
information.  
Standing orders programs authorize nurses and pharmacists where allowed by State law to 
administer vaccinations according to an institution or physician-approved protocol without the 
need for a physician's exam. They have been shown to improve vaccination rates in adults. The 
ACIP recently issued a recommendation that standing orders be implemented to improve 
immunization rates in a number of delivery environments including nursing facilities. Use of 
standing orders in assisted living facilities and intermediate care facilities for the mentally 
retarded is also appropriate. A copy of the paper containing their findings and recommendations 
is enclosed.  
We are requesting that you send a letter to all nursing facilities in your State urging them to 
implement  
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model standing orders programs for the remainder of 2000 influenza season, and to prepare for the 
2001  
influenza season. We are enclosing a draft model letter to nursing facilities for your convenience. 
In addition, we are requesting you to remind nursing facilities that Medicare Part B covers 
immunizations for both the annual influenza and the one-time pneumococcal vaccines provided to 
nursing facility residents, and that there are convenient ways to request Medicare reimbursement, 
e.g. roster billing. Part B Medicare reimbursement for influenza and pneumococcal vaccines is  available whether Medicare or Medicaid is reimbursing for nursing facility services.  
The Medicare program is evaluating the options available to it through the survey and 
certification program to encourage the use of standing orders. However, we did not want to miss 
the opportunity of improving immunization rates in nursing facilities by use of standing orders 
programs prior to Medicares issuing guidance on standing orders.  
As part of evaluating standing orders programs, nine States have agreed to participate in a broader 
Medicare pilot project to improve immunization rates in nursing facilities, and they have received a 
joint letter from HCFA and CDC similar to this letter. The pilot states are the District of Columbia, 
Florida, Hawaii, Idaho, Kentucky, Massachusetts, Minnesota, Montana and New Mexico.  
We urge any State Medicaid Agency that does not currently cover adult immunizations for 
individuals in nursing facilities to add coverage as an optional Medicaid service to assure that non-
Medicare eligible nursing facility residents are afforded the opportunity to be immunized. Federal 
matching for adult immunizations is available at the State's Federal matching rate for services.  
Together we can develop a strong national vaccination program to protect nursing facility 
residents and others at high risk of developing vaccine preventable infectious diseases. Thank you 
for your continuing cooperation in improving health outcomes for Medicaid beneficiaries.  
Sincerely,  
/s/  
Timothy M. 
Westmoreland 
Director  
Enclosures  
cc:  
HCFA Regional Administrators  
HCFA Associate Regional Administrators for Medicaid and State Operations  
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State Health Officers  
Lee Partridge Director, Health Policy Unit American Public Human Services Association  
Brent Ewig Senior Director of Access Policy Association of State and Territorial Health Officials   Joy Wilson Director, Health Committee National Conference of State Legislatures  
Matt Salo Director, Health Legislation National Governors Association  
Enclosure  
Fact Sheet on Influenza and Pneumococcal Disease  
Influenza epidemics, occurring nearly every year, are responsible for approximately 20,000 deaths per year in the 
United States. Pneumococcal disease accounts for an estimated 3,000 cases of meningitis, 50,000 cases of 
bacteremia and 500,000 cases of pneumonia each year. Pneumococcal disease is responsible for more deaths than 
any other vaccine-preventable bacterial disease. In fact, influenza and pneumonia combined represent the fifth 
leading cause of death in the elderly.  
Influenza and pneumococcal vaccinations are recommended for persons aged 65 years and older and for persons of 
any age who have medical conditions that place them at high risk for complications from influenza. While influenza 
vaccinations are administered annually, the pneumococcal vaccine is generally a once-in-a-lifetime vaccination that 
can be given at any time. Both influenza and pneumococcal vaccinations are covered preventive service benefits 
under Medicare Part B. Although coverage of immunizations for adults is an optional service under Medicaid, 
virtually all states cover immunizations for high-risk groups such as residents of nursing facilities.  
Nursing home residents, because of their age, underlying health conditions, and closed environment, are especially 
vulnerable to influenza and pneumococcal disease. During influenza outbreaks in nursing homes, more than half of 
the residents may become ill, and in some outbreaks as many as one-third of infected residents have died. 
Pneumococcal bacterium is the leading cause of serious pneumonia in Medicare beneficiaries and in our most 
vulnerable high-risk populations. The pneumococcal polysaccharide vaccine is effective in preventing 
pneumococcal bacteremia, an often-fatal complication  
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of pneumococcal pneumonia in adults. Studies indicate that influenza and pneumococcal 
vaccines are underutilized in institutional settings.  
The Advisory Committee on Immunization Practices (ACIP) recommends pneumococcal 
vaccination if a person's pneumococcal vaccination status is unknown. Due to a rapid emergence 
of antimicrobial resistance, especially to penicillin, a Quality Care Alert, formulated by 
representatives of the American Medical Association and a number of partner organizations, was 
issued in 1999 that supports the ACIP recommendations for pneumococcal vaccination.  
During 1999, both the Task Force on Community Preventive Services and the Southern California 
Evidence-Based Practice Center/RAND examined all of the available evidence and recommended 
standing orders immunization programs for adults in hospitals, nursing homes and clinics. Standing 
orders programs have been shown to improve vaccination rates in adults. Immunization standing 
orders authorize nurses and pharmacists where allowed by State law to administer vaccinations 
according to an institution or physician-approved protocol without the need for a physician's exam. 
In October of 1999, the ACIP adopted a statement recommending standing orders programs in 
many traditional and nontraditional health care delivery settings, including nursing facilities.   As part of our cooperative effort, HCFA and CDC encourage the implementation of standing orders 
programs for vaccination of adults in nursing facilities. We recommend a comprehensive 
assessment and vaccination program, involving nursing home staff and residents, to reduce the risk 
of outbreaks in nursing facilities. An influenza or pneumococcal outbreak puts staff at higher risk 
for infection as well. We encourage documentation of vaccinations provided to nursing home 
residents. This enables nursing homes to track the vaccination status of their residents and provides 
important medical history information to other health care facilities in the event that a resident is 
hospitalized or transferred or if an outbreak occurs.  
 
 
DRAFT MODEL LETTER  
Dear Nursing Facility Director:  
Influenza and pneumonia combined represent the fifth leading cause of death in the elderly. 
Influenza epidemics alone, occurring nearly every year, are responsible for approximately 20,000 
deaths per year in the United States. During influenza outbreaks in nursing homes, more than half 
of the residents may become ill, and in some outbreaks as many as one-third of infected residents 
have died. Pneumococcal bacterium is the leading cause of serious pneumonia in our most 
vulnerable high-risk populations. The pneumococcal polysaccharide vaccine is effective in 
preventing pneumococcal bacteremia, an often-fatal complication of pneumococcal pneumonia in 
adults. Influenza and pneumococcal immunization is our most potent, and unfortunately 
underutilized, weapon in eliminating needless deaths and illnesses from these diseases.  
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The Health Care Financing Administration (HCFA) and the Centers for Disease Control and 
Prevention (CDC) are coordinating efforts to promote influenza and pneumococcal vaccines for 
adult residents of nursing facilities. As part of that effort, HCFA has asked me to contact you to 
enlist your support. The goal is to immunize at least 90 percent of the institutionalized population 
to meet the Healthy People 2010 objectives through a national quality improvement program. A 
fact sheet on influenza and pneumococcal disease is enclosed for your information.  
I ask that you consider implementing immunization standing orders programs for influenza and 
pneumococcal immunizations to ensure that all your residents' immunization status is routinely 
assessed, and that all residents are offered influenza and pneumococcal vaccines. Standing orders 
programs authorize nurses and pharmacists where allowed under State law to administer 
vaccinations according to an institution or physician-approved protocol without the need for a 
physician's exam. The Advisory Committee on Immunization Practices, a panel of experts that 
advises CDC on issues related to vaccines, recently issued a recommendation that standing orders 
be implemented to improve immunization rates in a number of delivery environments including 
nursing facilities. A copy of the paper containing their findings and recommendations is also 
enclosed.   In addition, we strongly encourage you to offer annual influenza immunizations to your staff to 
prevent them from possibly infecting your patients and/or losing time from work. Also, the 
usually one-time pneumococcal immunization should be offered to staff over 65 or otherwise at 
risk for pneumococcal disease.  
HCFA has also asked me to remind you that Medicare Part B covers 100 per cent of the 
reasonable cost of both the annual influenza and the (normally) once-in-a-lifetime pneumococcal 
vaccines provided to nursing facility residents who are Medicare beneficiaries. The payment for 
the immunizations is in addition to payment for nursing facility services whether they are paid by 
Medicare or Medicaid. Your facility may also qualify for mass billing to request Medicare 
reimbursement, eliminating the need for separate billing for each beneficiary. Your Medicare Part 
B carrier can assist you with qualifying for mass billing. [Optional: Medicaid will cover the cost of 
immunizing nursing facility residents who are Medicaid beneficiaries only.]  
Thank you for your efforts to protect Medicare and Medicaid beneficiaries in your care who are at 
high risk of developing vaccine preventable infectious diseases, and for your continuing efforts to 
improve their health.  
Sincerely,  
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