If you’re about to make a move to Medicare from your private insurance, you might want to make sure you’ve had all your shots – especially your vaccination for shingles. That’s because coverage of recommended vaccines under Medicare is more complex than under private health insurance.
Under the Affordable Care Act, private insurers are required to cover all recommended vaccines as preventive care with no out-of-pocket costs to beneficiaries. But under Medicare, different vaccines are covered under different parts of Medicare with inconsistent out-of-pocket costs for beneficiaries.
In short, the shingles vaccine is not covered by Medicare unless you have a Part D prescription drug plan or an Advantage plan with prescription drug coverage; Even then, you’re likely to have out-of-pocket costs.
Medicare Part B covers certain vaccines, including flu and pneumonia, but not others, including shingles. Vaccines covered under Part B are provided to beneficiaries at no cost to them.
If you have a prescription drug plan, Medicare Part D, it will cover other commonly available vaccines, including those for shingles. But even then, Part D is not required to provide cost-free coverage of preventive treatments. What this means is medications and vaccines covered by Part D plans will likely be subject to deductibles and copays, resulting in out-of-pocket costs.
Which Vaccines Are Covered?
Medicare Part B covers the following vaccines: flu, pneumococcal and COVID. If the patient becomes at risk for tetanus, such as from stepping on a nail, then Part B covers a tetanus vaccine. If nothing happened to create the risk, tetanus vaccines are covered under Part D. Likewise, if a patient is considered at immediate or high risk for hepatitis B, that vaccine is covered under Part B at no cost to the beneficiary. Otherwise, it’s available only under Part D, which, again, may include out-of-pocket cost.
The Center for Medicare and Medicaid Services encourages Part D plans to include vaccine coverage with no out-of-pocket costs for beneficiaries. But a few Part D plans, which are offered through private insurers, have that feature.
What is Shingles?
According to the Centers for Disease Control and Prevention, shingles, also known as herpes zoster, is a painful rash that develops on one side of the face or body. The rash is made up of blisters that usually scab over in seven to 10 days and fully clear up within two to four weeks. The rash may be accompanied by other symptoms, including fever, chills, headache and upset stomach. In addition, 10% to 18% of patients can develop long-term, sometimes-debilitating nerve pain called postherpetic neuralgia. The older you are when you develop shingles, the higher your risk of postherpetic neuralgia.
The CDC currently recommends shingles vaccines for people 50 and older. According to the CDC, the two-dose Shingrix vaccine is 90% effective against the virus and postherpetic neuralgia. Recent research has also found that people who had COVID are 15% more likely to develop shingles, increasing the urgency for seniors to get shingles vaccines.
Will Medicare Offer Free Shingles Vaccines?
Concerned that the complicated and sometimes expensive Medicare vaccine coverage system is resulting in low rates among Medicare beneficiaries, bipartisan members of Congress have introduced legislation that would require all recommended vaccines to be covered under Part B at no cost to beneficiaries. This would include vaccines for both shingles and the combination vaccine for tetanus, diphtheria, and pertussis (Tdap).
According to bill sponsor Senator Shelley Moore Capito (RW.Va.), before the pandemic, the US spent more than $15 billion every year treating diseases that could have been prevented by vaccines.
The Protecting Seniors Through Immunization Act would also require beneficiaries to be given information about vaccines and require a study of vaccination rates among Medicare patients.
In addition, President Biden’s proposed 2023 budget recommends consolidating vaccine under Medicare Part B, “making more preventive vaccines available at no cost to Medicare coverage beneficiaries.” The budget also establishes a new Vaccines for Adults program to give uninsured adults free access to all recommended vaccines
Researchers at Avalere Health, a consultancy, found that out-of-pocket costs for vaccines are common among Medicare beneficiaries. As of 2020, Part D plans require a copayment for recommended vaccines 87% of the time, with an average copayment of $47 and a maximum as high as $100.
How to Get Free Shingles Vaccines
If you’re covered by a private health plan other than Medicare, such as through your employer or the healthcare exchanges under the Affordable Care Act, virtually all recommended vaccines are required by law to be provided at no cost to you. In that case, this means you can get a free shingles vaccine, as well as any other vaccine recommended by the CDC.
If you want to avoid any out-of-pocket cost for a shingles vaccine, you should consider getting the vaccine before switching from your private insurance to Medicare.
If you’re already on Medicare and are a beneficiary of a Part D plan or an advantage plan that includes prescription drug coverage, you will pay less for a vaccine under the plan after you meet the plan’s deductible in a given year.
In addition, some Medicare Part D beneficiaries qualify for “extra help” provisions, which aid in paying for their monthly premiums, annual deductibles, and co-payments related to Medicare prescription drug coverage.