Do health insurance cover vaccines?New rules for vaccination to prevent COVID-19, influenza, respiratory syncytial virus and other diseases

Now that flu season is approaching and there are new COVID booster and RSV vaccines, now is a good time to find out exactly which vaccines are covered by Medicare.

Because the immune system weakens with age, older adults are more susceptible than younger adults to infections such as influenza, pneumonia, shingles, and COVID-19, which may develop serious complications. The U.S. Department of Health and Human Services says vaccination is especially important for people with chronic medical conditions such as diabetes or heart disease.

Fortunately, the Inflation Reduction Act (IRA) of 2022 changed the rules, greatly expanding vaccination coverage and lowering vaccination costs for Medicare people starting in 2023.

“I think a lot of people don’t understand how Medicare relates to vaccines today because of their past experience with vaccines,” he said Medical insurance essentials By Dr. Tanya Feke, a family physician in Windham, N.H. “People need to be more aware that they have more choices than they did before.”

Inflation reduction bill makes major changes to vaccines

The IRA provides free adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) to people with Medicare prescription drug coverage. A complete list of ACIP vaccine recommendations and guidance is available on the organization’s website.

The recommended vaccines currently covered by Medicare include 8 vaccines: COVID-19; influenza; pneumococcal; shingles, RSV, hepatitis A and B, and Tdap (to prevent tetanus, diphtheria, whooping cough, or whooping cough).

The Adult Vaccine Access Alliance says that prior to the IRA, thousands of adults died or suffered serious health problems from vaccine-preventable diseases, in part because “Medicare and Medicaid recipients faced complex and costly hurdles when seeking to obtain vaccines. Condition”.

This new coverage could result in significant savings for many Medicare beneficiaries.

Before the IRA laws, Medicare beneficiaries often had to pay high copays or deductibles for some of these vaccines. In 2021, they paid an average of $70 per person ($234 million total) for recommended Part D vaccinations. Today, vaccinations for Americans without Medicare typically cost between $30 and $280; RSV, pneumococcal and shingles vaccines are the most expensive.

But Medicare is Medicare, and even the rules for free vaccines are a little complicated.

If you have a Part D plan, some vaccines are covered by Medicare Part B and other vaccines are covered by Medicare Part D. Additionally, some vaccines are only available to certain people on Medicare, and if you have a Medicare Advantage plan with a private insurance company, you may be charged an administration fee (although the fee is refundable).

You can get a personalized list of which vaccines you need from the Adult Vaccine Assessment Tool on the Centers for Disease Control and Prevention (CDC) website.

How Medicare Covers Vaccinations

Four of the major vaccinations are covered by Medicare Part B, and anyone who applies for Medicare can get health insurance. They are COVID-19, influenza, pneumococcal and hepatitis B vaccines, although Medicare only covers hepatitis B for beneficiaries with moderate or high risk for the virus.

The other four are covered by Medicare Part D, an optional prescription drug plan available to people who choose traditional Medicare or a Medicare Advantage plan. They are the Shingles vaccine, RSV, Tdap, and Hepatitis A vaccine.

Although you will not be charged for these vaccines, and Part B shots do not count toward your Part B deductible, you may have to pay if you have Medicare Advantage and go to an out-of-network provider for your shots The administrative fee is about US$40.

But you can – and should—Request reimbursement from your Medicare Advantage plan. “If you’re proactive and implement your plan, the plan has to give you that money back,” Fike said.

Where to get the vaccine

You can purchase the vaccine at pharmacies, community health centers, senior centers, community organizations, and sometimes even doctor’s offices.

One advantage of receiving vaccinations in a doctor’s office: Information about your immunizations will always remain in your medical record.

The Vaccines.gov website has an online tool to find COVID-19 and flu vaccines near you. The National Alliance on Aging has contracted with up to 150 senior centers to help seniors receive COVID-19 and flu vaccines and is helping 180 community organizations administer the vaccines.

Your state’s health department and its State Health Insurance Assistance Program (SHIP) staff can provide guidance about the vaccine and its availability where you live.

Medicare covers the most important vaccines for people over 65

COVID-19 vaccine

Newer COVID-19 booster shots are recommended for people of all ages. But their availability at chain pharmacies is a bit spotty. After making an appointment, it’s a good idea to call to make sure they’ve been vaccinated before going to the pharmacy.

If you have recently been infected with COVID-19, you should wait until you recover before getting vaccinated. According to the CDC, you may consider delaying getting your shot for three months after you recover, but certain factors, such as your risk of serious complications from COVID-19, mean you should get it sooner. If you recently had a COVID-19 vaccine, wait at least two months before getting a new one.

You can get the COVID-19 vaccine at the same time as your flu shot.

Flu vaccine

People 65 and older account for the vast majority of flu hospitalizations, and getting this year’s vaccine could reduce that risk by 56%, according to one study.

The CDC recommends that adults 65 and older get a high-dose flu vaccine by the end of October. There are three types of them: Fluzone High Dose Quadrivalent, Fluad Quadrivalent and Flublok Quadrivalent.

For maximum protection, the best time to get a flu shot is between September and November.

respiratory syncytial virus vaccine

RSV (respiratory syncytial virus) can cause severe respiratory illness in older adults. According to the CDC, approximately 60,000 to 160,000 RSV hospitalizations and 6,000 to 10,000 deaths occur each year among adults 65 and older.

The CDC says adults with chronic obstructive pulmonary disease, asthma, congestive heart failure, coronary artery disease, diabetes, brain aneurysms, stroke and chronic kidney disease are at increased risk for RSV-related hospitalization. The same goes for residents of long-term care facilities and the frail.

But there was no vaccine for older adults until May 2023, when the U.S. Food and Drug Administration approved two of the vaccines, one from Pfizer and the other from GlaxoSmithKline.

However, unlike many other vaccines, ACIP says people over 60 should talk to their doctor about whether they should get the RSV vaccine. That’s because this lens is so new.

“I would be inclined to consider this vaccine for people who have chronic conditions that put them at greater risk,” Fike said.

Shingles vaccine

Shingles, also known as herpes zoster, is a painful rash caused by the chickenpox virus. If you’ve had chickenpox, like most people over 40, the shingles virus is lurking in your body.

Fike noted that while for some people it’s just a painful inconvenience, shingles can also be “very debilitating” and “last for years.” The older you are when you get shingles, the more likely you are to have serious effects.

The Shingrix vaccine for shingles became available in 2017, and the CDC recommends that everyone age 50 or older get it. The vaccine comes in two doses, two to six months apart.

Before the IRA law covered the cost of this vaccine for people on Medicare, it was quite expensive for them.

pneumococcal vaccine

ACIP recommends that people 65 and older take pneumococcal vaccination to prevent respiratory infections if they have never been vaccinated or do not know if they have been vaccinated. Pneumococcal disease kills 18,000 people aged 65 and older each year.

You can get the PCV20 (Prevnar20) or PCV15 version; one year later, the PCV15 is given a follow-up shot of the PPSV23 vaccine.

It’s best to talk to your doctor to find out which pneumococcal vaccine is right for you.

Hepatitis A and B vaccine

Hepatitis is inflammation of the liver.

People with acute hepatitis A infection, usually caused by contaminated food or water, usually develop symptoms four weeks after exposure to hepatitis A but fully recover after a few weeks. Its vaccine is given in two doses over six months.

The CDC recommends hepatitis A vaccination for adults who are at higher risk for hepatitis A, including those who: have chronic liver disease or HIV, have traveled internationally, work in day care centers and hospitals, or are men and live with other people Male had sexual contact.

This vaccine is usually covered by Medicare Part D drug plans.

Most healthy adults infected with hepatitis B will not develop any symptoms. For some, this is a short-term condition, but for others, it can become chronic. In fact, chronic hepatitis B is the leading cause of liver cancer. Its vaccine is administered in two or three doses over six months.

Medicare Part B covers the hepatitis B vaccine if you are at moderate or high risk for the hepatitis B virus, such as if you have diabetes or hemophilia, have been diagnosed with end-stage renal disease, or work as a health care worker.

Tdap booster vaccine

Tdap booster helps protect against tetanus (muscle stiffness), diphtheria (which can cause difficulty breathing, heart failure, paralysis, or death), and whooping cough, or whooping cough (whooping cough) (which can cause severe coughing).

The CDC recommends a booster dose of Tdap or Td (similar vaccine, but does not protect against whooping cough) every 10 years.