Jesse Smedley
Jesse Smedley is the Principal Broker for iHealthBrokers and the founder, president, and CEO of Smedley Insurance Group, Inc. and iHealthBrokers.com. Since the inception of SIG in 2007, Jesse has been dedicated to helping people save money on their health insurance by providing them with resources to educate themselves on all their health insurance options, both under age 65 and Medicare beneficiaries. He is featured in many publications as well as writes regularly for expert columns regarding health insurance and Medicare.
With recent changes to Medicare Part D, beneficiaries now have access to more vaccinations covered at no additional cost than ever before. However, it’s crucial to understand how these changes affect you personally to ensure you don’t end up paying for a vaccine that should be covered at zero charge.
What is Medicare Part D?
Most vaccinations fall under Medicare Part D, which is the prescription drug plan of Medicare. Keep in mind that Medicare Part D is a voluntary or optional part of Medicare, meaning you must be enrolled in a Part D plan to have coverage for these vaccines. If you are enrolled in a Medicare Advantage plan that includes prescription drug coverage, you’ll also be covered for the vaccines discussed. To find a Medicare Part D plan, simply visit [medicare.gov](https://www.medicare.gov). You can search for a plan by entering your medications, which will help sort plans based on the lowest overall drug and premium costs. While normally it’s important to input all your medications to get an accurate estimate.
You can also find plans with no monthly premium, which may be ideal if you only need coverage for preventative measures like vaccines or just in case you need a plan to avoid Part D late enrollment penalties. These plans will help you avoid gaps in coverage while ensuring vaccines are covered.
Additionally, Medicare Advantage (Part C) plans often offer prescription drug coverage. To find a Medicare Advantage plan that includes drug coverage, simply search for Medicare Advantage plans and filter by those that include prescription drug coverage.
Understanding Vaccines Under Medicare Part B and Part D
While most vaccines are covered under Part D, some fall under Part B, which can get confusing. Part B generally covers treatments, while Part D focuses on preventive care. A great example of this distinction is the tetanus shot. – If you get a tetanus shot as a preventative measure (e.g., a booster shot), it’s covered under Part D. – However, if you need a tetanus shot after stepping on a rusty nail or following an injury, that would fall under Part B, as it’s considered treatment rather than prevention. It’s essential to know these differences to avoid unexpected costs.
Unfortunately, medical billing errors—especially in vaccine coding—are common, and you don’t want to find yourself with a large bill that could have been avoided.
Vaccines Covered Under Part B
Part B does cover several important preventative vaccines, such as: – Flu shots – Pneumonia vaccines – Hepatitis B vaccines (based on risk factors) – COVID-19 vaccines. For vaccines like these, there is no cost to you, as long as they meet the guidelines for preventative care. However, the line between preventative and treatment vaccines can sometimes be blurry, leading to potential confusion and mistakes.
Part D Vaccinations and No-Cost Coverage
Part D plans are required to cover vaccinations recommended by the Advisory Committee on Immunization Practices (ACIP) at no cost to beneficiaries. However, there are a few exceptions. Sometimes, you might be asked to pay for a vaccine upfront and be reimbursed later, which can create additional paperwork and financial inconvenience. The best way to avoid this issue is to ensure that the vaccine is administered at an in-network pharmacy. When your doctor prescribes the vaccine, the pharmacy will bill your Part D plan directly, with no upfront payment required from you—other than the administration of the vaccine itself.
Alternative Vaccine Administration Methods
If your doctor administers the vaccine, they will bill Part D for the vaccine itself. However, they may charge an administration fee, which you would need to seek reimbursement for from your Part D plan. Alternatively, if you go to an out-of-network pharmacy, you’ll need to submit a claim to your Part D plan for reimbursement. Again, this can be more paperwork and a hassle to manage. To avoid this inconvenience, it’s best to get the vaccine administered at an in-network pharmacy where the billing process is streamlined, and you don’t have to pay upfront.
With these recent changes, you should have vaccine coverage, whether in-network or out-of-network. However, as we’ve discussed, there can be complications, especially with upfront payments or out-of-network care. It’s important to carefully review your plan and understand the rules surrounding vaccine coverage to avoid any unexpected costs
