RSV Vaccines Aren’t Covered By Medicare For These Vulnerable Groups

Topline

Some seniors and pregnant people—among the most vulnerable to respiratory syncytial virus (RSV)—are forced to pay out of pocket (upwards of $300) for an RSV vaccine this year due to a loophole that means it’s not covered under all Medicare plans.

Key Facts

Seniors and infants are the most vulnerable groups facing the respiratory syncytial virus (RSV), and there are two Food and Drug Administration approved vaccines designed to protect seniors against RSV and one for infants through their pregnant parents.

The RSV vaccines (like shingles and hepatitis A vaccines) are covered under Medicare Part D, which covers vaccines as prescription drugs, but may require a vaccine administration fee.

But around 16 million Medicare beneficiaries aren’t enrolled in Part D, according to data from health policy research organization KFF, so they have to pay for the RSV vaccine out-of-pocket, leaving some patients with a $330 bill, the New York Times reports.

In comparison, several common vaccines like the Covid and flu vaccines are covered under Part B, which covers the full costs of vaccines, including vaccine administration fees.

Even those signed up for Part D face hurdles: Doctor’s offices are reimbursed for administering vaccines under Part B but not Part D, so they’re referring patients with Part D coverage to pharmacies to pay for the RSV vaccine out of pocket, but some patients abandon the vaccine at that point.

Can Medicare Recipients Add Part D Coverage?

Medicare beneficiaries are only able to add, drop or switch Part D plans during open enrollment periods. There’s an open enrollment period between October 15 and December 7 for all beneficiaries, but coverage doesn’t begin until January 1. For those in a Medicare Advantage Program, there’s an enrollment period between January 1 and March 31, or within the first three months of getting Medicare. Part D coverage for this starts the first of the next month. There’s a special enrollment period that varies, but it allows people to change plans who’ve had major life changes—like moving to a new address or losing coverage.

Big Number

2.1 million. That’s how many times children under the age of five visit the hospital because of RSV each year in the U.S., according to the Centers for Disease Control and Prevention. It causes upwards of 160,000 outpatient visits in adults 65 years and older. RSV causes between 6,000 and 10,000 deaths in seniors, and between 100 and 300 deaths in kids under five each year.

Crucial Quote

“This is just the result of poor policy making,” Richard Hughes IV, a vaccine-law expert at the firm Epstein Becker Green and the former vice president of public policy at Moderna told the New York Times. “I think that vaccines, all vaccines, should be accessible in all settings of care, and so this fragmentation is really just not good.”

Key Background

RSV vaccines by Pfizer and GlaxoSmithKline for people aged 60 years and older were approved by the FDA earlier this year and have shown to be up to 94% effective at preventing severe illness. Pfizer’s RSV vaccine was also approved for infants in August through a shot administered to pregnant parents, and was 82% effective at preventing severe illness.