Does Medicare Pay For Flu And Pneumonia Shots

Whats Included In Medicare Vaccine Coverage

Original Medicare covers several common vaccines, but you may need to meet certain eligibility requirements first. For instance:

• Pneumococcal Vaccine: You can receive the first shot at any time, but inorder to receive a second one, you must get it within one year of the first.
• HepatitisB Vaccine: Your doctor must determine that youre at a medium or higherrisk in order to receive the Hep B vaccine. Factors that may increase your riskinclude if you live with someone who has the virus, you have diabetes,hemophilia, or End-Stage Renal Disease, or if you work in a health careenvironment and regularly come in contact with bodily fluids.

You may be able to receive the vaccines covered under Original Medicare at your doctors office or at a nearby pharmacy. You should consult with your healthcare professional ahead of time to ensure that they accept Medicare, and that you meet any necessary eligibility guidelines. Youll typically be able to receive covered vaccines at no additional cost, as long as your healthcare provider accepts Medicares payment terms.

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.

Will Medicare Cover A New Coronavirus Vaccine Once Available

A vaccine for the 2019 novel coronavirus isnt currently available. But many pharmaceutical companies are developing vaccines in the hopes of protecting against the COVID-19, the disease caused by the virus.

A vaccine could put an end to a pandemic that has taken thousands of American lives. And whenever a coronavirus vaccine is available, Medicare and Medicare Advantage will cover the costs, according to the CARES Act.

The CARES Act states that a person with Medicare will not have to pay any cost-sharing for the vaccines. This means you wont have to pay a copayment or deductible toward getting a coronavirus vaccine.

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Does Medicare Cover Other Vaccines

Flu shots arent the only vaccines covered by Medicare.

Medicare Part B and Medicare Advantage plans also cover preventive vaccines such as pneumonia shots and Hepatitis B shots. Medicare Part B and Medicare Advantage plans may also cover vaccines such as rabies shots if they are considered medically necessary by a doctor.

Specific costs, including monthly premiums, deductibles and coinsurance 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 and get you enrolled in a plan that works for you.

Find Medicare Advantage plans in your area

Or call 1-800-557-6059TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles hes written, helping Americans better understand their health insurance and Medicare coverage.

Christians work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

Christians passion for his role stems from his desire to make a difference in the senior community. He strongly believes that the more beneficiaries know about their Medicare coverage, the better their overall health and wellness is as a result.

How Much Does The Pneumonia Vaccine Cost

Medicare Part B covers the total cost of Prevnar 13, with no copays, as long as the beneficiary gets the vaccine through a provider who accepts Medicare. Enrollees in Medicare Part C plans can also get full coverage for the shots if administered through an in-network provider. Without coverage, the cost of a Prevnar 13 pneumonia shot is about $263. Because pneumonia shots are covered by Medicare Part B, beneficiaries can get vaccinated at no cost even if they don’t have a Medicare Part D prescription drug plan.

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Should You Get A Flu Shot

In general, every person with diabetes needs a flu shot each year. Talk with your doctor about having a flu shot. Flu shots do not give 100% protection, but they do make it less likely for you to catch the flu for about six months.

For extra safety, it’s a good idea for the people you live with or spend a lot of time with to get a flu shot, too. You are less likely to get the flu if the people around you don’t have it.

The best time to get your flu shot is beginning in September. The shot takes about two weeks to take effect.

If youre sick , ask if you should wait until you are healthy again before having your flu shot. And don’t get a flu shot if you are allergic to eggs.

You are advised to continue to take the general precautions of preventing seasonal flu and other communicable illnesses and diseases:

• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash. If you dont have a tissue, cough or sneeze into your elbow, not your hand.
• Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.
• Avoid touching your eyes, nose, or mouth. Germs spread that way.
• Try to avoid close contact with sick people.
• If you get sick, stay home from work or school and limit contact with others to keep from infecting them.

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

Or call 1-800-557-6059TTY Users: 711 to speak with a licensed insurance agent. We accept calls 24/7!

About the author

Christian Worstell is a senior Medicare and health insurance writer with MedicareAdvantage.com. He is also a licensed health insurance agent. Christian is well-known in the insurance industry for the thousands of educational articles hes written, helping Americans better understand their health insurance and Medicare coverage.

Christians work as a Medicare expert has appeared in several top-tier and trade news outlets including Forbes, MarketWatch, WebMD and Yahoo! Finance.

A current resident of Raleigh, Christian is a graduate of Shippensburg University with a bachelors degree in journalism.

• Medicare Enrollment Guide

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D Prescription Drug Plans

Part D plans cover most preventive vaccines that you could need to receive. Although Part B covers a few vaccines noted above, most of your vaccine needs will be covered by Part D plans. Part D plans, like Part C plans, are offered by private insurance companies. This means that you will have a provider network as well as a unique formulary that tells you how much each drug-related service will cost.

You wont need a Part D plan to get your pneumococcal vaccine.

Will Medicare Cover The Flu Shot

Find Cheap Medicare Plans in Your Area

Medicare covers the full cost of yearly flu shots. To get the shot for free, be sure to use a provider that accepts your plan’s payment, whether you’re enrolled in Original Medicare or a Medicare Advantage plan. You must use a plan provider if you have a Medicare Advantage HMO, but PPO members are covered for both in-network and out-of-network flu shots.

If a second flu season breaks out in the same calendar year, your doctor may recommend you get a second shot. Both Original Medicare and Medicare Advantage plans cover a second vaccine if your doctor approves it.

Since the flu vaccine is free with Medicare, the main difference between plans is where you can get the shot. You won’t be charged for the shot as long as you use a provider covered by your plan.

• Important flu facts

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Are There Different Vaccines For Medicaid

No. Medicaid vaccines are the same as youd receive through any other program or form of insurance. And Medicaid-covered vaccines are always administered by qualified professionals such as pharmacists and healthcare workers. This also applies to COVID-19 vaccines. At the height of the pandemic, some mass vaccination sites also brought in active-duty troops from the National Guard to give shots, and they were also qualified to do so.

How Much Regional Difference Is There Between States As To Whether Medicaid Covers Adult Vaccines

It varies, but most states cover at least one of the recommended adult vaccines. Some only cover flu vaccines for adults.

Coverage varies widely depending where you live. Among the majority of states that offer at least some coverage, it can range from coverage for both kids and adults to an age limit that caps out at 19 or 20 years old.

So, in some areas, older Americans looking for a shingles vaccine might find it difficult to get coverage. That can be problematic given that Shingrix, the CDC-recommended shingles vaccine, costs about $200 a dose out of pocket and requires two doses. Its now also approved for use in immunocompromised adults.

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Where To Get Your Shots

You can get your flu and pneumonia shots at the following locations:

• Your doctors office. Call your primary care physician and make an appointment. Your office visit copay may apply for the visit, but the shots will come at no cost.
• A pharmacy. Call your local pharmacy before you go to make sure they offer flu and pneumonia shots. Youll also want to make sure that the pharmacy accepts your Medicare plan. Our pharmacy directory can help you find a location, too.
• A community health center. You can check with your local health department to see if there are community health centers that offer these shots and accept your Medicare plan.

What Vaccines Does Medicare Cover

Vaccines can become less effective over time. Even individuals fully vaccinated as children may need to update their immunizations. Medicare Parts B and D offer vaccination coverage.

Medicare Part B covers shots for the flu, hepatitis B, pneumococcal , and COVID-19. Medicare covers 100 percent of the cost of these vaccines if you go to an approved provider, and you do not have to pay a deductible or coinsurance. Medicare Advantage plans are also required to provide these vaccines at no additional costs.

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City, State

Medicare covers one flu shot per flu season, which runs from November to April, and not the calendar year. For example, if an individual gets a flu shot in January and again in November of the same year, Medicare would pay for both.

Medicare covers two different pneumonia shots. Medicare recipients can get the first shot at any time and it will cover the second shot if it’s administered at least one year after the first shot.

Hepatitis B shots are free for anyone considered medium or high risk for contracting the virus. End-stage renal disease and diabetes are two conditions that place individuals into a higher risk category. A medical professional can help determine an individuals risk level.

Keeping current on your vaccinations is one of the best ways to prevent serious illness and disease. Talk with your doctor to determine what vaccines you need to minimize risks to your health.

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Does Medicaid Cover Vaccines For Adults

In addition to the COVID-19 vaccine, the CDC recommends 13 vaccines for adults:

• Tetanus, diphtheria, pertussis

• Measles, mumps, rubella

• Meningococcal A, C, W, Y

• Meningococcal B

• Haemophilus influenzae type B

Under Medicaid, coverage for these vaccines, and others, depends on the policies of the state you live in. A recent study found that 22 out of 51 state Medicaid programs covered all 13 recommended vaccines.

For those who live outside of those states, there may be free and low-cost vaccine options that can help. Or, if you have coverage but the cost is still too high, a coupon, like those available from GoodRx, may help you save money.

Scenario: Billing For Influenza And Pneumococcal Vaccines

If influenza vaccine and pneumococcal vaccine are administered at the same encounter, can an administration fee be billed for each vaccine?

The Centers for Medicare and Medicaid Services address this question in its guide on Medicare Part B Immunization Billing.

When a beneficiary gets both the seasonal influenza virus and pneumococcal vaccines on the same visit, do I continue to report separate administration codes for each type of vaccine?

Yes, see https://www.cms.gov/Medicare/Coverage/CoverageGenInfo/ICD10.html for individual Change Requests and coding translations for ICD-10. Use separate administration codes for the seasonal influenza virus and pneumococcal vaccines. Medicare pays both administration fees if a beneficiary gets both the seasonal influenza virus and the pneumococcal vaccines on the same day.

1/11/16Pneumococcal vaccine administeredG00091Z23

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When To Get Your Shots

The best time to get your flu and pneumonia shots is any time after July 1 each year. This is because flu season typically begins in the fall. Peak months for the flu season in Michigan are November, December, January, February, March and April.

The flu spreads quickly during those peak months. So, getting vaccinated early is important, because it gives your body a chance to protect itself.

Influenza And Pneumonia Billing

Medicare covers both the costs of the vaccine and its administration by recognized providers. There is no coinsurance or co-payment applied to this benefit and a beneficiary does not have to meet his or her deductible to receive it. Assignment must be accepted on all vaccine claims and a physician order is not required.

Influenza and pneumonia vaccinations and administration are covered under Part B, not Part D.

If a physician sees a beneficiary for the sole purpose of administering one of these vaccines, an office visit cannot be billed. However, if the beneficiary receives other services which constitute an office visit, then one can be billed.

If both vaccines are administered on the same day, providers are entitled to receive payment for both administration fees.

The diagnosis code used for these vaccines and administration is Z23 .

On this page, view the below information:

• Pneumococcal HCPCS and CPT Codes

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Which Medicare Plans Cover Vaccines

Medicare divides its coverage into parts, and each part covers specific medical costs. Heres what each Medicare part may cover or not cover when it comes to vaccines:

• Part A.Part A is the part of original Medicare that covers hospital and inpatient stays. It doesnt usually cover vaccines. Even if youre in the hospital and get a flu shot , the hospital will still bill your Medicare Part B plan.
• Part B.Part B is the portion of original Medicare that pays for most medical costs. The vaccines that Medicare covers are listed above.
• Part C. Medicare Advantage is an alternative to original Medicare . Medicare Advantage plans must cover all the vaccines that original Medicare does.
• Part D.Part D is the portion of Medicare that pays for prescription drugs. It will cover vaccines if Medicare Part B doesnt cover them. Your Part D formulary should explain which vaccines your plan covers.
• Medigap.Medigap is Medicare supplement insurance that helps cover the out-of-pocket costs related to healthcare. Medigap doesnt pay for vaccine costs because you dont have out-of-pocket costs when getting vaccines approved under Part B.

Its always a good idea to know how Medicare may pay for your vaccine before you get it. Sometimes, Medicare may have certain rules: For example, you might need to get the vaccine from a certain company or at a Medicare-approved facility.

Medicare Coverage For The Pneumonia Vaccine

Most preventive vaccines are covered under Part D, the prescription drug part of Medicare. Medicare Part B covers a few specific vaccines, like the two pneumonia vaccines. Medicare Advantage plans, sometimes called Part C, also cover the pneumonia vaccines, along with other vaccines you may need.

If you are enrolled in original Medicare , or a Part C plan, you are automatically eligible for the pneumonia vaccines. Since there are two types of vaccines for pneumonia, you and your doctor will decide if you need one or both vaccines. Well get into the details of the two different types a little later.

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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
• Pneumococcal:
• 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.