Get your Medicare vaccine or prepare to pay at the right place

Medicare has a notorious history of treating vaccinations unequally. Here’s an example from one of my clients, Ed.

My doctor’s office contacted me because my DTaP (diphtheria, tetanus, and pertussis) booster shot was due. I made an appointment. I then received the vaccine and received a bill for $148 ($101 for vaccine and $47 for administration).

How is this going? I have never received a bill from a doctor’s nurse for a flu or pneumonia shot.

Medicare Part B, or Medicare, covers flu and pneumonia vaccinations with no deductibles or copays. When the coronavirus pandemic swept the world, Part B paid the price. Medicare also covers hepatitis B vaccines for people at moderate or high risk, as well as vaccines directly related to injury (such as tetanus) or direct exposure to a disease or condition (including rabies or botulism).

Then, all other vaccines that seniors need to stay healthy are not covered under Part B. Top of the list is shingles, followed by hepatitis B vaccine and DTaP vaccine for non-high-risk groups. The Centers for Medicare and Medicaid Services (CMS) requires Part D prescription drug plans to provide these services, and all of these plans are subject to deductibles and cost-sharing. For example, each shingles shot comes with a copay of about $200 once the plan’s deductible is met (maximum $485 in 2022), which is definitely not fair for Part D vaccinations treatment.

Fortunately, as of January 1, 2023, Medicare will treat all vaccines equally for cost sharing. There is no deductible and no deductible or coinsurance required for Part D vaccinations.

Costs may be the same, but management is still treated differently

Medicare beneficiaries can get the Part B vaccine at a doctor’s office or pharmacy. If you have Original Medicare, any Medicare-designated doctor or pharmacy can provide vaccinations. If you choose Medicare Advantage, you should see a doctor or pharmacy in the plan’s network. Just show up and show the necessary insurance card.

As Ed learned, the Part D vaccine works differently. He asked why there was a problem with his doctor’s office. Part D covers drugs from in-network providers. CMS considers physician offices to be out-of-network. This is because Part D networks are defined as pharmacy networks only.

He then asked about the bill, something he hadn’t seen with other vaccinations. (The bill includes costs associated with the Part D vaccine, including the cost of the vaccine ingredients, dispensing fees (if applicable), and administration fees.) Ed called Medicare, his supplemental insurance company, and his Part D drug plan. He learned that because the injections were given out-of-network, he would have to pay his doctor’s bill and then submit a drug plan form to receive reimbursement. The form asks for information that Ed will not provide, such as the doctor’s NPI (National Provider ID) and National Drug Code (FDA’s identifier). He must contact his doctor’s office for help.

Will Ed and others be able to get all the vaccines from their doctors? When the first shingles vaccine, Zostavax, emerged about 15 years ago, MLN Matters Radio noted: “Requiring beneficiaries to pay the full cost of the vaccine to their doctor out of pocket and then have it reimbursed by the plan is not the best solution “. CMS encourages physicians to use the web-based portal to submit applications for Part D vaccination and agree to accept full payment from the program. Based on the questions I’ve received, this is still a work in progress.

I found reimbursement forms for several plans online. Buried somewhere, you might find a sentence or two claiming that the claim is subject to the program’s rules; in other words, the program will pay for vaccinations administered at pharmacies. It is possible for members of a reimbursement plan to be reimbursed less than the amount paid to the physician’s office.

Save yourself the hassle and bills

Next time you need a Part D vaccine (such as the new RSV (respiratory syncytial virus)), go to a pharmacy in your plan’s network. You will not receive a bill or have to file a claim.

Ed learned his lesson. Next time he will go to the online pharmacy.

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