II 116th CONGRESS 1st Session S. 1872 IN THE SENATE OF THE UNITED STATES June 13, 2019 Ms. Hirono (for herself, Mrs. Capito , and Mr. Whitehouse ) introduced the following bill; which was read twice and referred to the Committee on Finance A BILL To amend title XVIII of the Social Security Act to provide information regarding vaccines for seniors as part of the Medicare & You handbook and to ensure that the treatment of cost sharing for vaccines under Medicare part D is consistent with the treatment of vaccines under Medicare part B, and for other purposes.

1. Short title This Act may be cited as the Protecting Seniors Through Immunization Act of 2019 . 2. Findings Congress makes the following findings: (1) The immune system deteriorates with age, leaving older adults more susceptible to many vaccine-preventable diseases that could result in hospitalizations and other costly medical interventions. (2) Vaccines play an essential role in preventing disease, thereby helping to keep older adults active and independent. (3) There are more than a dozen immunizations recommended for adult populations by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, including— (A) influenza; (B) tetanus, diphtheria, pertussis (Tdap); (C) measles, mumps, rubella (MMR); (D) herpes zoster (shingles); (E) human papillomavirus (HPV); (F) pneumococcal; (G) hepatitis A; (H) hepatitis B; and (I) meningococcal. (4) Through new research and technology, additional vaccines may be approved for older adults. (5) Although immunizations are lifesaving and cost-effective interventions, adult vaccination rates in the United States remain below Federal Healthy People benchmarks. (6) There are disparities in adult vaccination rates across different races and ethnicities with rates generally lower among Hispanics, African Americans, and Asian Americans. (7) Important vaccines, including those for shingles and Tdap, are covered under the Medicare Prescription Drug Program under part D of title XVIII of the Social Security Act. Coverage under the Medicare part D has resulted in barriers to optimal and consistent uptake, including lack of patient and provider awareness, beneficiary cost sharing, and low provider reimbursement, as well as geographic, cultural, and linguistic challenges. (8) The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends the Tdap vaccine should be administered every 10 years for all ages. According to the Centers for Disease Control and Prevention Surveillance of Vaccination Coverage Among Adults in the United States, National Health Interview Survey, 2016, vaccination rates remain low for tetanus and diphtheria (Td) and tetanus and diphtheria with acellular pertussis (Tdap) for adults age 65 and older, at 58 percent and 20 percent respectively. (9) Being up-to-date with Tdap is especially important for adults who are around babies, because they are not only protecting their own health but helping to form a cocoon of disease protection around the baby during the first few months of life. (10) The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommends the shingles vaccine for individuals aged 50 and older. While vaccine coverage for shingles has increased each year since licensure, in 2016, only 33 percent of adults over 60 years reported receiving the vaccine. (11) Almost 1 out of every 3 people in the United States will develop shingles in their lifetime. The risk increases with age, and 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. (12) A 2018 study of Tdap and shingles vaccine claims in Medicare part D demonstrated that higher out-of-pocket cost sharing was associated with higher rates of cancelled vaccination claims, suggesting vaccination was abandoned. In this study, cost sharing of $51 or greater was associated with a 2 to 2.7-times greater rate of cancelled vaccination claims compared with $0 cost sharing. (13) There is an opportunity to improve education around adult immunization, including the risks and consequences of vaccine-preventable disease, and which vaccines are recommended for older adults. 3. Provision of information regarding vaccines for seniors as part of Medicare & You handbook and coverage of adult vaccines recommended by the Advisory Committee on Immunization Practices 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 (e) before the comma at the end; and (B) by adding at the end the following new subsection: (e) The notice provided under subsection (a) shall include information with respect to vaccines for seniors, including information with respect to coverage of adult vaccines recommended by the Advisory Committee on Immunization Practices (as defined in section 1860D–2(b)(8)(B)) 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 adult vaccines recommended by the Advisory Committee on Immunization Practices under Medicare part D (1) Provision of educational materials regarding the availability of adult vaccines recommended by the Advisory Committee on Immunization Practices 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: (vii) 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 adult vaccines recommended by the Advisory Committee on Immunization Practices (as defined in section 1860D–2(b)(8)(B)). . (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 adult vaccines recommended by the Advisory Committee on Immunization Practices consistent with treatment of vaccines under part b (A) In general 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, the following shall apply with respect to an adult vaccine recommended by the Advisory Committee on Immunization Practices (as defined in subparagraph (B)): (i) No application of deductible The deductible under paragraph (1) shall not apply with respect to such vaccine. (ii) No application of coinsurance There shall be no coinsurance under paragraph (2) with respect to such vaccine. (iii) No application of initial coverage limit The initial coverage limit under paragraph (3) shall not apply with respect to such vaccine. (iv) No cost sharing above annual out-of-pocket threshold There shall be no cost sharing under paragraph (4) with respect to such vaccine. (B) Adult vaccines recommended by the advisory committee on immunization practices For purposes of this paragraph, the term adult vaccine recommended by the Advisory Committee on Immunization Practices means a vaccine approved for use by adult populations and in accordance with recommendations of the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention. . (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 adult vaccines recommended by the advisory committee on immunization practices 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 an adult vaccine recommended by the Advisory Committee on Immunization Practices (as defined in subparagraph (B) of such section). . (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, and in collaboration with the Administrator of the Centers for Medicare & Medicaid Services, shall conduct a study on the uptake of vaccines among the Medicare beneficiary population, 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 vaccines recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention in the Healthy People 2020 goals; (B) ensure that baseline targets focus on reducing racial and socioeconomic disparities in the vaccine coverage rates for all adult vaccines; (C) help facilitate immunization of Medicare beneficiaries, 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; (D) support adoption of the HEDIS adult immunization status composite measure (Tdap, pneumococcal, influenza, and zoster) in order to close gaps in adult immunization performance measurement and incentivize vaccination through adoption of evidence-based measures; and (E) strengthen immunization information systems to allow all States to have electronic databases for immunization records. (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.