Does Medicare cover vaccines? The new rules for shots that protect against COVID, flu, RSV, and more
Now that flu season is approaching and there are new COVID booster and RSV shots, it’s a good time to understand exactly which vaccinations Medicare covers.
Since immune systems weaken as we age, older people are more likely to get the flu, pneumonia, shingles and COVID-19 than younger ones, with potentially serious complications. Vaccinations are especially important for people with chronic health conditions like diabetes or heart disease, according to the U.S. Department of Health and Human Services.
Fortunately, the Inflation Reduction Act (IRA) of 2022 changed the rules to greatly broaden vaccination coverage and reduce the cost of the jabs for people on Medicare starting in 2023.
“I think a lot of people, because of their past experience with vaccines, don’t understand where Medicare is with vaccines today,” says Medicare Essentials author, Dr. Tanya Feke, a family physician in Windham, N.H. “People need to be more aware that they have more options than they had before.”
The Inflation Reduction Act’s big vaccine changes
The IRA made adult vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) available at no cost for people with Medicare prescription drug coverage. There’s a complete list of the ACIP vaccine recommendations and guidelines on the group’s site.
The recommended vaccines now covered by Medicare include the Big 8: COVID-19; flu; pneumococcal; shingles, RSV, hepatitis A and B, and Tdap (protection against tetanus, diphtheria and pertussis or whooping cough).
The Adult Vaccine Access Coalition said that before the IRA, thousands of adults died or suffered serious health problems from vaccine-preventable diseases partly due to the “complicated and costly landscape faced by Medicare and Medicaid recipients when seeking access to vaccines.”
This new coverage is a huge money-saver for many on Medicare.
Before the IRA law, Medicare beneficiaries often had high copayments or deductibles for some of those vaccines. In 2021, they paid an average of $70 per person—$234 million in total—for recommended Part D vaccinations. Today, Americans who aren’t on Medicare are often charged between $30 and $280 get a vaccine; the RSV, pneumococcal and shingles vaccines are the priciest.
But Medicare being Medicare, even the no-cost vaccine rules are a bit complicated.
Some vaccines are covered by Medicare Part B and others by Medicare Part D if you have a Part D plan. Also, certain vaccines are only covered for certain people on Medicare and if you have a Medicare Advantage plan from a private insurer, you may get hit with an administrative fee (though the fee is reimbursable).
You can learn which vaccinations you need by getting a personalized list from the Adult Vaccine Assessment Tool at the U.S. Centers for Disease Control and Prevention (CDC) site.
How Medicare covers vaccinations
Four of the major vaccinations are covered by Medicare Part B, medical insurance available to anyone who applies for Medicare. They are the COVID-19, flu, pneumococcal and hepatitis B vaccines, although Medicare only covers Hep B for beneficiaries who are at medium or high risk for the virus.
The other four are covered by Medicare Part D, the optional prescription drug program available to people with Traditional Medicare or Medicare Advantage plans. They are the shingles, RSV, Tdap and hepatitis A vaccines.
Although you won’t be charged to get these vaccines and the Part B shots won’t count towards your Part B deductible, if you have Medicare Advantage and go to an out-of-network provider for a jab, you might be charged an administrative fee of $40 or so.
But you can—and should—apply to your Medicare Advantage plan for reimbursement. “If you’re proactive and reach out to your plan, the plan has to give you that money back,” said Feke.
Where to get vaccines
You can get vaccines at drugstores, community health centers, senior centers, community-based organizations and sometimes in doctor’s offices.
One advantage of receiving vaccinations at your doctor’s office: information about your immunizations will always be current in your medical records.
The Vaccines.gov site has an online tool to find COVID-19 and flu vaccines near you. The National Coalition on Aging has contracted with up to 150 senior centers to help older adults get COVID-19 and flu vaccines and is helping to administer the vaccines at 180 community-based organizations.
Your state’s health department and its State Health Insurance Assistance Program (SHIP) staff can provide guidance about vaccines and their availability where you live.
Medicare coverage for the most important vaccines for people 65+
COVID-19 vaccine
Updated COVID-19 booster shots are recommended for people of all ages. But their availability at drugstore chains has been a bit spotty. After making an appointment, it’s best to call the pharmacy before showing up to ensure it has the vaccination.
If you’ve had COVID recently, you should wait until you recover to get the vaccine. You may consider delaying the shot for three months after recovery, according to the CDC, but certain factors, like your risk for serious complications from COVID mean you should get it sooner. And if you’ve received a COVID shot recently, wait at least two months before getting this new one.
You can get a COVID shot at the same time as a flu shot.
Flu vaccine
People 65 and older represent the vast majority of hospitalizations from the flu and getting this year’s vaccine reduces that risk by 56%, according to one study.
The CDC recommends adults 65 and older get a high-dose version of the flu vaccine before the end of October. There are three of them: Fluzone High Dose Quadrivalent, Fluad Quadrivalent and Flublok Quadrivalent.
The best time to get a flu shot, for maximum protection, is from September through November.
RSV vaccine
RSV (respiratory syncytial virus) can cause of severe respiratory illness in older adults. There are roughly 60,000 to 160,000 hospitalizations and 6,000 to 10,000 deaths annually among adults 65 and older due to RSV, according to the CDC.
The CDC says adults with COPD, asthma, congestive heart failure, coronary artery disease, diabetes, brain aneurysms, strokes and chronic kidney disease are at increased risk for RSV-associated hospitalization. So are residents of long-term care facilities and people who are frail.
But there hasn’t been a vaccine for older adults until the Food and Drug Administration approved two of them in May 2023—one from Pfizer and one from GSK.
Unlike many other vaccines, however, the ACIP says people over 60 should check with their doctors about whether they should get the RSV vaccination. That’s because this shot is so new.
“I would tend to be looking at this vaccine for folks who have any chronic conditions that make them at greater risk,” said Feke.
Shingles vaccine
Shingles, also known as herpes zoster, is a painful skin rash caused by the virus responsible for chickenpox. The shingles virus is lying dormant in your body if you ever had chickenpox, as most people over 40 have.
While just a painful inconvenience for some, shingles can also be “very debilitating” and “last for years,” Feke noted. The older you are when you get shingles, the more likely you are to have serious effects.
The Shingrix vaccine against shingles came out in 2017, and the CDC recommends everyone 50 or older get it. This vaccine has two doses, spaced two to six months apart.
Before the IRA law covered this vaccine’s cost for people on Medicare, it was quite expensive for them.
Pneumococcal vaccine
The ACIP recommends people 65 and older get the pneumococcal vaccine to prevent respiratory infections if they’ve either never received it or don’t know if they have. Pneumococcal disease kills 18,000 people 65 and older annually.
You can get the PCV20 (Prevnar20) or the PCV15 version; PCV15 is followed up a year later with a dose of the PPSV23 vaccine.
It’s best to consult with your doctor regarding which pneumococcal vaccine is right for you.
Hepatitis A and B vaccines
Hepatitis is inflammation of the liver.
People with the acute infection of hepatitis A, which often comes as a result of contaminated food or water, often show symptoms after four weeks of exposure but make a full recovery in weeks. Its vaccine is given in two doses over six months.
The CDC recommends the hepatitis A vaccine for adults at increased risk for the disease, which includes people who: have chronic liver disease or HIV, travel internationally; work in day care centers and hospitals or are male and have had sexual contact with other men.
This vaccine is usually covered by a Medicare Part D drug plan.
Most healthy adults don't have symptoms when they're infected with hepatitis B. For some, it's a short-term illness, but for others it can become chronic. In fact, chronic hepatitis B is the leading cause of liver cancer. Its vaccine is given in two or three doses over six months.
Medicare Part B covers the hepatitis B vaccine if you are at medium or high risk for the virus, such as having diabetes or hemophilia, having a diagnosis of end-stage renal disease or being a health care worker.
Tdap booster vaccine
The Tdap booster helps prevent tetanus (stiffening of the muscles), diphtheria (which can lead to difficulty breathing, heart failure, paralysis or death) and pertussis or whooping cough (which can case violent coughing).
The CDC recommends getting a booster dose of Tdap or Td (a similar shot but one that doesn’t protect against pertussis) every 10 years.
This story was originally featured on Fortune.com
