You may think it is obvious that all preventive vaccines should be covered by Medicare. Seniors are considered vulnerable, and thus, most preventive vaccines are recommended and covered. However, where and how they are covered is not as obvious. I had a client call recently and share that he was billed over $300 for a vaccine he received at a Minute Clinic by a provider, likely a Nurse Practitioner. We discovered that the vaccine is covered through his Part D plan but not Part B. The minute clinic staff later shared that he would not have owed anything if he had gotten that particular vaccine at the pharmacy rather than the minute clinic. Read on to learn more and avoid this surprise bill!
Vaccines Covered by Medicare Part B
Medicare Part B is the ‘medical’ part of your coverage. This can be on your red/white/blue card if you use Original Medicare as your primary insurance. It would also be covered through your Advantage Plan as a medical benefit. The vaccines billed through Part B or the ‘medical’ part of your plan include the flu shot, COVID-19, Pneumonia and Hepatitis B [only if you are medium to high risk]. The influenza and pneumococcal vaccines are covered 100%. The COVID vaccine is also covered 100%. However, the Hepatitis B vaccine may be subject to the Part B deductible or, in the case of Advantage Plans, copays. Another important thing to know is that to ensure proper billing, have these vaccines administered by a medical provider. In other words, at your PCP's office, urgent care, or MinuteClinic. Many people get their flu shot at a pharmacy. In this case, just be sure to check with the pharmacist to ensure they bill your medical or Part B coverage.
Vaccines Covered by Part D or your Drug Plan
Shingles and RSV are commonly administered and paid by your prescription drug plan. This can be a stand-alone drug plan or part of your Advantage Plan, which includes drug coverage. The best way to ensure you aren’t billed is to have these administered at a pharmacy. You can have them administered by your PCP or a medical provider, but be sure, prior to getting it, that they understand it needs to be billed to your Part D drug plan and NOT through medical. You might be surprised that the medical office staff isn’t always familiar with the different billing methods and coverage details. There are times when you have to be proactive and bring it to their attention. You may also find out that they cannot bill your Part D plan for you. In this case, you will need to obtain documentation to get reimbursement. See below for more information on managing this process.
What If I do Get Billed?
If you do get billed because the provider administered a vaccine they cannot bill for, you can get reimbursement. Keep your receipt and request a claim form from the provider to assist in providing the necessary documentation. Physicians have guidance regarding charging their patients for the vaccine and its administration. When it is a Part D covered vaccine, the physician’s office should complete a claim form and give it to you to file as an out of network claim to get reimbursed.
Other Vaccines
There are other vaccines that are not considered ‘preventive.’ For example, a Tetanus shot is not covered as a preventive vaccine. Tetanus is covered under your medical or Part B, but only as a result of injury or exposure. I had a client go to a wellness visit, and his doctor advised he get a Tetanus vaccine because it had been over 10 years since he had one. He later got a bill for nearly $300. He joked and said if he had stepped on a rusty nail, the Tetanus vaccine would have been totally covered. He is right, of course. Another example would be a rabies vaccine if you get bit by an animal. You can find out more about all recommended vaccines at https://www.cdc.gov/acip-recs/hcp/vaccine-specific/
CDI is here to help you manage your healthcare costs and find the best options for your unique situation. We can meet in person or virtually. Reach out if you would like more information. Email carrie@cdi-cares.com or check out www.cdi-cares.com for a contact page and other helpful blogs.
Resources:
https://www.ncoa.org/article/medicare-and-medicaid-now-fully-cover-preventive-vaccines/