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Vaccines are an all-important first line of defense against a wide range of infectious diseases. They are crucial to public health because of their ability to prevent individuals from contracting and spreading diseases within their communities.
Coronavirus vaccines, for instance, have now been administered to over 270 million Americans, or more than 81% of the U.S. population. U.S. citizens who are eligible for Medicare are also guaranteed several other vaccines.
Recipients should understand their vaccine coverage under each type of Medicare and how beneficiaries can get access to these vaccines.
Vaccines covered by Medicare Part B
Here are the vaccines covered under Medicare Part B, which covers medical insurance:
- Influenza (Flu) Vaccines: Medicare Part B covers the seasonal flu vaccine, which is updated annually to target the most prevalent strains of the flu virus.
- Pneumococcal Vaccines: Medicare Part B covers two types of pneumococcal vaccines – the pneumococcal polysaccharide vaccine (PPSV23) and the pneumococcal conjugate vaccine (PCV13). These vaccines help protect against infections caused by pneumococcal bacteria, which can cause pneumonia, meningitis, and other severe illnesses.
- Hepatitis B Vaccines: Medicare Part B covers hepatitis B vaccines for individuals at high or intermediate risk for the disease, including those with chronic liver disease, healthcare workers, and individuals with certain medical conditions.
Vaccines covered by Medicare Part D
Medicare Part D, which provides prescription drug coverage, may cover certain vaccines that are not covered under Part B. The specific vaccines covered under Part D can vary depending on the insurance plan you choose, as Part D plans are offered by private insurance companies. Some commonly covered vaccines under Medicare Part D include:
Shingles Vaccine: Medicare Part D typically covers the shingles vaccine, which helps prevent herpes zoster (shingles) in older adults. There are several shingles vaccines available, including Zostavax and Shingrix.
Tdap Vaccine: Medicare Part D may cover the Tdap vaccine, which protects against tetanus, diphtheria, and pertussis (whooping cough).
Vaccines that are “Reasonable and Necessary”: Medicare Part D may also cover other vaccines that Centers for Medicare & Medicaid Services (CMS) are deems “reasonable and necessary.” These may include vaccines for conditions such as pneumonia, meningitis, or other diseases.
Vaccines not covered by Medicare
While Medicare provides coverage for a wide range of vaccines, it doesn’t cover certain vaccines. These include:
Travel Vaccines: Vaccines required for travel purposes, such as yellow fever or typhoid vaccines, are generally not covered by Medicare.
Non-Medicare Preventive Vaccines: Vaccines that are recommended for preventive purposes but not specifically covered by Medicare guidelines may not be covered.
Eligibility Criteria for Coverage
Multiple factors determine eligibility for vaccine coverage under Medicare. They include:
Age requirements
Medicare generally covers vaccines for individuals who are eligible for Medicare benefits. This typically includes individuals who are 65 years of age or older. However, individuals under 65 may also be eligible for Medicare coverage if they have disabilities or are suffering from end-stage renal disease (ESRD).
Health conditions that warrant vaccine coverage
There are a few specific health conditions that may warrant vaccine coverage under Medicare. Individuals with chronic medical conditions or weakened immune systems who are more susceptible to vaccine-preventable diseases may qualify for coverage.
The specific conditions considered here include chronic lung disease, heart disease, diabetes, and other conditions that increase the risk of complications from vaccine-preventable diseases.
Enrollment
To receive vaccine coverage under Medicare, you must be enrolled in the appropriate Medicare program. Original Medicare (Part A and Part B) covers some vaccines, while other vaccines may be covered under Medicare Part D, which provides prescription drug coverage.
Some vaccines may also be covered under Medicare Advantage plans (Part C), which are offered by Medicare-approved private insurance companies.
Remember, coverage for vaccines may vary depending on the specific Medicare plan you have, as individual plans have different coverage requirements and limitations.
Accessing vaccines under Medicare Coverage
You can gain access to the vaccines covered under your Medicare plan through multiple channels. They include:
Vaccination at a doctor’s office
One option is to receive your vaccination at a doctor’s office. You can schedule an appointment with your primary care physician or any healthcare provider who is eligible to administer vaccines. The doctor’s office will bill Medicare directly for the cost of the vaccine and its administration.
Vaccination at a pharmacy
Medicare beneficiaries also have the option to receive vaccinations at participating pharmacies. Many approved pharmacies such as CVS, Walgreens, and Rite Aid offer vaccination services. You can simply visit a participating pharmacy and request the vaccine. The pharmacy will administer the vaccine and bill Medicare directly.
Vaccination at a clinic
Another option is to receive the vaccine at a clinic. Community health clinics, public health departments, and other healthcare facilities may offer vaccination services. These clinics often provide vaccines at a reduced cost or on a sliding fee scale based on income. You can inquire about vaccine availability and schedule an appointment at the clinic of your choice.
Costs of vaccines under Medicare
The costs of vaccines under Medicare can vary depending on the specific vaccine, the type of Medicare coverage you have, and where you receive the vaccination. Here are some key points to consider:
Medicare Part B Coverage
Vaccines for influenza (flu), pneumococcal diseases, and hepatitis B are some of those covered under Medicare Part B. The plan covers 100% of the cost when administered by a healthcare provider who accepts Medicare assignment. This means you should not have any out-of-pocket costs for these vaccines as long as they are deemed medically necessary.
Medicare Part D Coverage
Some vaccines may be covered under Medicare Part D, which provides prescription drug coverage through private insurance plans. The specific vaccines covered under Part D can vary depending on the insurance plan you choose.
Make sure to review your Part D plan’s formulary or contact your insurance provider to understand which vaccines are covered and whether they involve any associated costs, such as copayments or deductibles.
Pharmacy and provider Costs
While Medicare covers the cost of the vaccine itself, there may be additional costs related to administration fees or services. If you receive the vaccine at a doctor’s office or clinic, Medicare should cover the administration fees.
If you choose to get vaccinated at a pharmacy, however, there may be a nominal fee for administering the vaccine. These costs can vary depending on the pharmacy and the specific vaccine.
Out-of-pocket costs and deductibles
Make sure to find out if any deductibles or out-of-pocket costs are associated with your Medicare vaccine coverage. For instance, if you have a deductible for Medicare Part B, you may need to meet that deductible before Medicare covers the cost of vaccines.
There may also be copayments or coinsurance for vaccines if you have a Medicare Advantage or a Medicare Part D plan.
Schedule a call with CoverRight today to find out more about Medicare vaccine coverage.
FAQs About Medicare vaccine coverage
Is the COVID vaccine covered by Medicare?
Yes, Medicare provides coverage for the COVID-19 vaccine. Both the vaccine itself and its administration are covered under Medicare Part B. Medicare beneficiaries are eligible to receive the COVID-19 vaccine at no cost. This coverage applies to all COVID-19 vaccines that have received emergency use authorization from the US Food and Drug Administration (FDA) or have been approved by it.
Does Medicare cover travel vaccines?
Generally, Medicare does not cover vaccines required for travel abroad, such as yellow fever or typhoid vaccines. That’s because they are not considered “reasonable and necessary” for Medicare coverage. If you require travel vaccines, you may need to explore other options, such as private insurance plans, travel clinics, or paying out-of-pocket for the vaccines.
What should I do if I have questions about Medicare coverage for vaccines?
If you have questions about Medicare coverage for vaccines or need more information, there are a few steps you can take:
Contact Medicare: You can contact Medicare directly by calling 1-800-MEDICARE (1-800-633-4227) or visiting the official Medicare website at medicare.gov. They can provide general information and answer specific questions related to your coverage.
Reach out to Your Medicare Insurance Provider: If you have a Medicare Advantage plan or a Medicare Part D plan, you can contact your insurance provider directly for information about vaccine coverage, costs, and any associated requirements.
Utilize Online Resources: There are online resources available that can help you understand your Medicare coverage options and answer questions. One such resource is CoverRight, a website that offers personalized assistance with Medicare coverage options that suit your needs.
