Medicare and Medicaid Coverage for Adult Vaccines
Medicare and Medicaid cover several recommended vaccines for adults, with Medicare Part B covering influenza, pneumococcal, hepatitis B (for high-risk individuals), and Tdap vaccines, while Medicaid coverage varies by state but generally includes all ACIP-recommended vaccines. 1
Medicare Vaccine Coverage
Medicare Part B Coverage
- Influenza (flu) vaccine: Annual dose covered at 100% with no copayment 1
- Pneumococcal vaccines:
- Pneumococcal polysaccharide vaccine (PPSV23) for all adults age 65 and older
- Pneumococcal conjugate vaccine (PCV13) based on shared clinical decision-making for adults age 65 and older 1
- Hepatitis B vaccine: Covered for Medicare beneficiaries at high risk (e.g., diabetes, end-stage renal disease, healthcare workers) 1
- Tetanus shots: Covered when related to injury or illness (Td) or as part of wound management 1
Medicare Part D Coverage
- Shingles vaccine (Zoster): Recombinant zoster vaccine (RZV, preferred) or live zoster vaccine (ZVL) 1
- Tdap vaccine (Tetanus, diphtheria, pertussis) when not covered under Part B 1
- Hepatitis A vaccine 1
- MMR vaccine (Measles, mumps, rubella) 1
- Varicella vaccine (Chickenpox) 1
- Meningococcal vaccines (MenACWY and MenB) 1
- Human papillomavirus (HPV) vaccine (for eligible adults through age 45) 1
Medicaid Vaccine Coverage
Medicaid coverage varies by state but has improved significantly over time 2:
- 17 state Medicaid programs cover all ACIP-recommended vaccines for adults while prohibiting copayments 2
- Most states have maintained or expanded vaccination coverage benefits for adults over the past decade 2
- Coverage is typically more comprehensive for Medicaid expansion states under the Affordable Care Act
Commonly Covered Vaccines Under Medicaid
- Influenza (annual)
- Pneumococcal
- Tetanus, diphtheria, pertussis (Tdap)
- Hepatitis A and B
- MMR
- Varicella
- Meningococcal
- HPV (for eligible adults)
- Haemophilus influenzae type b (Hib) for certain high-risk adults 1
Important Considerations for Providers
Coverage Gaps and Barriers
- Despite coverage, adult vaccination rates remain suboptimal and well below Healthy People 2020 targets 3, 4
- Racial and ethnic disparities persist in vaccination coverage 1
- Adults with health insurance have 2-5 times higher vaccination coverage than those without 1
Financial Considerations
- Medicare Part B vaccines typically have no copayment when administered by participating providers 1
- Medicare Part D vaccines may require copayments or be subject to deductibles
- Medicaid copayment policies vary by state, with nearly half of programs prohibiting copayments for vaccines 2
Clinical Practice Recommendations
- Implement systematic approaches to adult immunization including standing orders and patient reminders 1
- Use electronic medical record alerts to reduce missed opportunities for vaccination 1
- For adults with unknown vaccination records, generally administer recommended vaccines if no documentation exists (except for influenza and pneumococcal vaccines) 1
Special Populations
- Adults with chronic conditions: Both Medicare and Medicaid provide enhanced coverage for certain vaccines (e.g., hepatitis B for diabetics) 1
- Institutionalized adults: Special coverage considerations apply for long-term care facilities 5
- High-risk groups: Medicaid enrollees have disproportionately higher rates of vaccine-preventable diseases compared to commercially insured adults 6
The burden of vaccine-preventable diseases remains substantial among adult populations, particularly those covered by Medicaid 6. Healthcare providers should be familiar with coverage policies to maximize vaccination opportunities and reduce financial barriers for their patients.