Medicare Advantage Plans May Cover More Vaccines Than Original Medicare
Medicare Advantage plans are sold by private insurance companies as an alternative to Original Medicare.
Every Medicare Advantage plan must provide the same hospital and medical benefits as Medicare Part A and Part B, and most plans include Medicare prescription drug coverage.
MAPDs must help cover a number of commercially available vaccines that arent covered by Original Medicare when reasonably and medically necessary to prevent illness. However, specific rules of administration and costs will vary depending on the Medicare Advantage plan you enroll in.
A licensed insurance agent can help you compare Medicare Advantage plans in your area, including what vaccinations may be covered.
Find Medicare plans that cover your vaccinations
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About the author
Christian Worstell is a licensed insurance agent and a Senior Staff Writer for MedicareAdvantage.com. He is passionate about helping people navigate the complexities of Medicare and understand their coverage options.
His work has been featured in outlets such as Vox, MSN, and The Washington Post, and he is a frequent contributor to health care and finance blogs.
Christian is a graduate of Shippensburg University with a bachelors degree in journalism. He currently lives in Raleigh, NC.
Where you’ve seen coverage of Christian’s research and reports:
Options To Get Your Flu Shot With Our Medicare Advantage Plans
Schedule an appointment with your doctor
Visit your doctor before the flu season begins.
Don’t have a doctor?
Visit any location for these chain pharmacies
Our in-network flu shot providers bill us directly so you wont have to pay up front.
Get a flu shot out of network
You can also go to a flu shot provider that is not in our flu network. With this option, you need to:
- Send a copy of your receipt to the claims address on your Aetna ID card
- Include your member ID on the receipt
Will Medicare Pay For My Flu Shot
En español | Medicare Part B pays for one flu shot in each flu season, which typically runs from November through April, regardless of whether youre enrolled in the original Medicare program or in a Medicare Advantage plan.
If youre in original Medicare, the shot is free if you have it administered by a doctor or pharmacist who accepts Medicare assignment that is, has agreed to accept the Medicare-approved payment as full reimbursement for providing this service.
If youre in a Medicare Advantage plan , the shot is still free. But you may be required to have it administered by a doctor who is in the plans provider network.
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Is It Cheaper To Get A Vaccine At My Doctors Office Or A Pharmacy
You may feel more comfortable getting shots at your healthcare providers office. Your provider knows your patient history and can provide a one-on-one experience. If you choose to get vaccinated at your providers office, keep in mind you may be billed for an office visit in addition to the cost of the shot.
For the COVID-19 vaccine, your provider shouldnt charge you if the vaccine was the only service you received. You should ask for a refund if you believe you were billed in error for the COVID-19 vaccine.
You can also get immunizations against flu, pneumonia, shingles, and other conditions at your local pharmacy. Youll be responsible for any copays or deductibles depending on your prescription drug plan, but you wont have an office visit copay.
Plus, your vaccine record will be kept on file as part of your permanent pharmacy history. When you get vaccinated at your pharmacy, your information is entered into the state immunization registry, which can be accessed by your doctor, Dr. Schaffner says.
How To Enroll In Medicare Plans For Flu Shot Coverage
Medicares annual open enrollment period runs from Oct. 15 through Dec. 7. Most people enroll in Medicare when they first become eligible at age 65. If youre already collecting social security benefits, its likely that youre already automatically enrolled in Original Medicare therefore, theres no need for you to sign up for anything.
If youre not collecting social security benefits, you have to enroll yourself, which you can do within the three months before and after the month you turn 65. If you miss this window and dont qualify for an exception, youll likely have to wait for Medicares next enrollment period or pay a late enrollment penalty.
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Medicare Part B Covers Preventive Services Including Flu Shots
Medicare Part B is your medical insurance. It covers preventive services, like the flu shot. Medicare pays for one shot per season but may cover a second if its medically necessary. Medicare coverage includes flu shots that are approved by the U.S. Food and Drug Administration for people over the age of 65. Covered flu shots include Fluad and Fluzone High-Dose, according to the CDC.
Dr. Ganguli recommends the high-dose flu vaccination for anyone older than 65.
There are other types of influenza vaccines approved for adults, however, not specifically for people over the age of 65. These can be given to people over 65 years of age if the high-dose flu vaccine is unavailable or not preferred for any reason. These include:
- Quadrivalent cell-based influenza shot including Flucelvax Quadrivalent
- Recombinant quadrivalent influenza shot including Flublok Quadrivalent
Medicare does not cover nasal spray flu vaccines, as the FDA has not approved them for this age group.
Medicare Part B also covers COVID-19 vaccines, a seasonal H1N1 swine flu vaccine, a pneumococcal vaccine, and hepatitis B shots for individuals considered high-risk.
Part B also includes certain shots if theyre related to treatment for illness or injury. For example, if your doctor treats an injury with a tetanus shot.
Should Seniors Get Flu Shots
Whether or not you get a vaccine is a personal health decision, so talk to your doctor and ensure you’re making an educated decision. The CDC recommends that everyone age 6 months and up get a flu shot with some exceptions for health issues.
The CDC also notes that adults age 50 and up should be on the priority list for receiving flu shots if there is ever a shortage of vaccines. That’s because older adults can be more at risk when it comes to some of the serious side effects that come with the flu.
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Does Medicare Cover High
High-dose flu shots are made available each year to individuals age 65 and over. According to the Centers for Disease Control and Prevention, data suggests that older people get a better immune response from the high-dose flu shots. This is because the immune systems weakens as individuals age and a higher dose of vaccine provides better protection against the flu.
Since older individuals are at higher risk for severe complications from the flu, some doctors recommend the high-dose flu shot for their patients age 65 and over. The CDCs Advisory Committee on Immunization Practices does not endorse a preference at this time for the high-dose flu shot over the standard one its recommendation is only that everyone age 6 months and over get the shot unless a health condition prevents it.
If your health care provider recommends the high-dose flu shot, Medicare Part B may cover the injection at no cost to you once each year during flu season if your doctor accepts assignment.
Note that if you are enrolled in a Medicare Advantage plan, your flu shot is also covered. Medicare Advantage must provide, at a minimum, all the same benefits as Original Medicare , except for hospice care which is still covered under Part A. You must continue to pay your Part B premiums if you enroll in Medicare Advantage, as well as any additional premiums required by your plan.
New To Medicare?
Does Medicare Advantage Cover Flu Shots
Medicare Advantage plans cover flu shots the same way as Original Medicare. You can get a free flu vaccine once per calendar year from any provider covered by your plan.
You don’t need a referral to get an annual flu vaccine, even with a Medicare Advantage HMO.
If there are two flu seasons within the same calendar year, Medicare Advantage plans cover a second vaccine if your doctor approves it.
To be sure you’re covered, contact your Medicare Advantage plan to find out where you can go for your flu shot. With an HMO, for example, you need to stay within your plan’s provider network. If you have a PPO, you can go to an out-of-network provider and still get the shot for free.
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Importance Of Flu Shots For Seniors
Americans are living longer than ever before. Eating well, staying active and working with your doctor to control any medical problems you might have will help you enjoy a healthy life well into your senior years. Still, aging takes a toll on your immune system making it less capable of fighting infections like the flu. As you get older, you’re more likely to catch the flu. You’re also more likely to develop serious problems like pneumonia if you come down with the flu. Americans 65 and older are more likely than any other age group to be hospitalized for the flu, and approximately nine out of 10 flu deaths in the U.S. occur in seniors, according to the Centers for Disease Control and Prevention .
Vaccines Covered By Medicare Part D
Medicare Part D covers all commercially available vaccines needed to prevent illness. You can get Part D coverage through a stand-alone Medicare prescription drug plan or a Medicare Advantage plan that includes drug coverage.
Vaccines covered by Part D include the following:
- Shingles vaccine: One-time vaccine given in two shots over two to six months
- Tdap vaccine : One shot if youve never been vaccinated, and a booster every ten years
- Other vaccines covered: Vaccines that are “reasonable and necessary” to prevent illness and are not covered by Part B
Part D may also cover vaccines you may need if you are traveling internationally. Talk with your doctor about your travel plans and ask what vaccines are recommended.
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Medicare Part D: Vaccine Coverage
Payment for Part D-covered vaccines and their administration are made solely by the participating prescription drug plan. This includes all preventive vaccines not covered under Medicare Part B.
When providing a Part D covered vaccine to a Medicare patient, the physician should charge the patient for the vaccine and its administration. To facilitate the patient’s reimbursement by his or her Part D plan, the physician’s office should complete a CMS-1500 claim form for the vaccine and administration service and give it to the patient to file as an unassigned, out-of-network claim.Some patients may also request a prescription for preventive vaccines and their administration to meet their Part D plan requirements to have this prescription filled by contracted providers .
Medicare Covers Your 2020 Flu Shot
Things may be different this flu season, but your flu shot coverage is the same. We know that cost might be a factor when deciding whether to get a flu shot, but heres some good news: youll pay nothing when you get yours from a doctor or other qualified health care provider who accepts assignment.
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Vaccines Covered By Medicare Part B
Medicare Part B covers three important vaccines as part of its preventive care benefits.
Covered vaccines include the following:
- Flu vaccine: Annual vaccine given in one shot before or during flu season, usually November through April
- Pneumonia vaccine: One-time vaccine given in two shots at least one year apart
- Hepatitis B vaccine: One-time vaccine given in two to four shots over one to six months for people who are medium to high risk, including people with diabetes
Part B also covers vaccines you may need if youre exposed to a harmful virus or bacteria by accident. You might need a tetanus shot, for example, if you step on a rusty nail. Or you may need rabies shots if youre bitten by a stray dog.
Medicare Part D Flu Shot Coverage
Medicare Part D prescription drug plans are optional, and plans offer different formularies , copayments, coinsurance and deductibles. Some Part D plans even offer $0 deductibles.
Medicare Part D plans the flu shot, along with many other vaccines. However, you need to have Part B in order to have Part D as well. And when you have Part B, it will pay the full price for your flu vaccine.
Part D coverage will pay for other vaccinations, such as:
- Shingles vaccine
- Tdap vaccine for tetanus, diphtheria, and pertussis
- MMR vaccine
- BCG vaccine for tuberculosis
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Do I Need The Shingles Vaccine And How Much Does It Cost
The CDC recommends adults 50 years and older should get two doses of the shingles vaccine. Shingles is a viral infection that can cause several symptoms, including:
Other serious symptoms
Two doses of Shingrix will protect you against shingles and postherpetic neuralgia , the most common shingles complication. PHN affects your nerve fibers and skin, leading to burning pain that persists after other symptoms of shingles, such as the rash and blisters, have gone away.
Studies suggest Shingrix was between 91% and 97% effective in preventing shingles after two shots, depending on your age. Since your risk of acquiring shingles and PHN increases as you get older, strong protection against shingles after 50 is important.
Most Medicare Part D cover the shingles shots, as well as Medicare Advantage plans with built-in Part D coverage. Depending on your plan, you may have to pay toward your deductible, a copay, or pay out-of-pocket and get reimbursed later.
If you havent met your plans deductible for the year, youll have to pay full price for the vaccines. If you have to pay upfront, the average retail cost of is about $200 per dose. You need two doses of Shingrix, 2 to 6 months apart.
Get Your Flu Shot Today
Getting a flu shot is a simple way you can help yourself and others be healthier this flu season. If your UnitedHealthcare health plan is provided through your employer:
- Your flu shot is covered at $0 out-of-pocket1
- You can get a flu shot at more than 50,000 locations
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Medicare Part B: Vaccine Coverage
Medicare Part B provides preventive coverage only for certain vaccines. These include:
- Influenza: once per flu season
- Hepatitis B: for persons at intermediate- to high-risk
Administration services for these preventive vaccines are reported to Medicare using HCPCS codes as follows:
- G0008 administration of influenza virus vaccine
- G0009 administration of pneumococcal vaccine
- G0010 administration of Hepatitis B vaccine
The diagnosis code to report with these preventive vaccines is:
- Z23 Encounter for immunization
Other immunizations are covered under Medicare Part B only if they are directly related to the treatment of an injury or direct exposure Coverage of other vaccines provided as a preventive service may be covered under a patient’s Part D coverage.
How Much Does The Flu Shot Cost
If you have Original Medicare coverage, the flu shot will cost you $0.
If youre wondering where you can get the flu shot, the answer is lots of places, including your doctors office or a local pharmacy. If you have a Medicare Advantage plan, contact the plan provider to find out where exactly you can go for your flu shot. Most places accept Medicare Advantage plans, according to medicare.gov.
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Does A Person With Medicare Get Flu Shots For Free
If a person has Medicare Part B, a Medicare Advantage plan, or private health insurance, they can get a flu shot for free.
The Affordable Care Act requires that insurance companies cover the cost of the flu shot. Plus, under the ACA, insurers cannot charge a copayment, per the Department of Health & Human Services.
A person should check with the site providing the shot to make sure they accept assignment from Medicare or accept Medicare Advantage. People with private insurance should check their plan to make sure they can get the shot from a particular location for free.
Some insurance plans cover the shot only if a person receives it from their doctor. Other plans provide coverage if the shot comes from certain other locations as well.
What Do Medicare Advantage Plans Pay For Flu Shots
Medicare Advantage plans cover 100 percent of the Medicare-approved amount for an annual flu shot during the fall or winter months.
This means that you will typically not have to pay a coinsurance or copayment for your flu shot, as long as you visit a doctor who accepts Medicare and the terms of your Medicare Advantage plan.
Some Medicare Advantage plans also cover some common vaccines that are NOT covered by Medicare Part B, such as:
- Tdap shot
- Shingles vaccine
- Meningococcal vaccines
Coverage rules and costs for vaccinations like the ones above will vary by plan.
In addition to the standard hospital and medical benefits of Medicare Part A and Part B, most Medicare Advantage plans also include coverage for other benefits, such as:
- Membership to wellness programs such as SilverSneakers
Check with your health care provider if you have questions about a specific immunization or vaccine that is not listed here.
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