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Does Medicare Cover Pneumonia Shots ?

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Having actually had pneumonia when I was in my thirties, I would advise anyone, especially the elderly to go and get the pneumococcal vaccine, and then to keep up with the booster shots. If it goes poorly, as it did for me, and you end up in the ICU at hospital, it is no joke, and frankly I don’t want my elderly loved one to go through that.

If you are enrolled in Medicare, Medicare Part B will cover two separate pneumococcal shots,  and if you use a Medicare-enrolled doctor, or other qualified health care provider, who accept the Medicare-approved price it is free.

Once you have received the first pneumococcal vaccine you have to wait at least one year to have the second shot if your doctor, or health care provider, decides that you need it. 

What are pneumococcal bacteria,  and pneumonia ?

 

Infections caused by the pneumococcal bacteria lead to a number of illnesses  –

 

  • ear infections
  • sinus infections
  • pneumonia
  • meningitis

 

Streptococcus pneumoniae is the most common cause of bacterial pneumonia in the US.

As I said in my introduction, I have had pneumonia, and spent 9 days in intensive care.

My lungs filled right up with fluid, and I only just got away without being placed in an induced coma on a ventilator.

It took my lungs, or at least it felt like it did, about 6 months to fully recover, after I was placed on steroids for quite some time – Prednisolone.

I only bring this up to say, if you have any respiratory, or other underlying health concern, get the pneumococcal vaccination, because it really doesn’t bear thinking about catching pneumonia.

It was a terrifying and horrible experience, and the drugs they have to pump into you are not at all enjoyable.

So, if you have any concern I wouldn’t hesitate to get vaccinated, and if you are over 65 just go and do it.

I was lucky because I was young, had great doctors and nurses, and I made it through without any complications, other than immense difficulty breathing and the fluid.

 

But some people may develop –

 

  • bacteria which spread into the bloodstream, causing organ failure
  • infections in the fluid build up in the lungs
  • lung abscess, needing surgery or drainage

 

You don’t want to be battling such illnesses at an advanced age.

The Pneumococcal Vaccine ?

 

All adults over 65 are recommended by the Centers for Disease Control and Prevention to get the pneumococcal vaccine.

If a person  certain underlying health conditions they may get it once every 5 years.

The CDC recommends that –

For adults 65 years or older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and want to receive PPSV23 ONLY:

  • Administer 1 dose of PPSV23.
    • Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Administer this last dose at least 5 years after the prior PPSV23 dose.

For adults 65 years or older who do not have an immunocompromising condition, cerebrospinal fluid leak, or cochlear implant and want to receive PCV13 AND PPSV23:

  • Administer 1 dose of PCV13 first then give 1 dose of PPSV23 at least 1 year later.
    • Anyone who received any doses of PPSV23 before age 65 should receive 1 final dose of the vaccine at age 65 or older. Administer this last dose at least 5 years after the prior PPSV23 dose.
    • If the patient already received PPSV23, give the dose of PCV13 at least 1 year after they received the most recent dose

You can find and read the whole section “Pneumococcal Vaccination: Summary of Who and When to Vaccinate” here on the CDC website.

Younger people with certain underlying health conditions and chronic health conditions should get the vaccine as well.

Does Medicare pay for Pneumonia shots at a pharmacy ?

 

The pneumococcal vaccine shots in pharmacies are totally covered by Medicare Part B if the pharmacy is Medicare-enrolled and accepts assignment – that is, that they accept the Medicare-approved price for the vaccine.

If that is the case, the pharmacy will simply bill Medicare, and you have nothing to pay at all.

Neither to the pharmacy, nor to Medicare.

If you have Medicare Advantage, you just have to use the correct pharmacy in the plan’s network, and you won’t have anything to pay.

 

Does Medicare pay for pneumonia shots at Walgreens ?

 

Medicare Part B covers the pneumococcal vaccines at Walgreens.

If you are enrolled in Medicare Part B, you can get the vaccines without deductible or co-pay.

Walgreens gives both types of pneumococcal vaccine –

PPSV23 – pneumococcal polysaccharide vaccine gives protection against 23 strains of pneumonia bacteria

PCV13 – pneumococcal conjugate vaccine gives protection against 13 strains of pneumonia bacteria, including the strains most likely to cause serious disease.

You find out more about pneumonia shots at Walgreens here on their site.

You should take along your insurance information, and a photo ID when you get your vaccine. 

You can also make an appointment at a Walgreens near you here on their site.

 

Medicare reimbursement for Pneumovax 23 ? 

 

The two pneumococcal vaccines available in the US are –

 

  • Pneumococcal Conjugate Vaccine (PCV13)
  • Pneumococcal Polysaccharide Vaccine (PPSV23) or Pneumovax 23

 

If you are enrolled in Medicare, the two vaccines are a cost free benefit, so long as you use a Medicare-enrolled Doctor, or other qualified health care provider, who accepts assignment.

How much does it cost to get a pneumonia shot ?

 

If you don’t have insurance for your pneumonia shots, the CDC lists the prices in the private sector,  for the autumn of 2020, as –

 

  • PCV13 – $202.00
  • PPSV23 – $105.19

 

You can check the cost of most vaccines in the private sector here on the CDC website.

Does Medicare Advantage cover pneumonia shots ?

 

With a Medicare Advantage Plan, you are covered for the same services as Medicare Parts A and B, so you have the same coverage for vaccinations.

You will though have to check with your insurer which are the pharmacies and doctors that you are allowed to use, so that you get your shot for nothing.

Make sure you stick within your plan’s network, or you may not be covered at all.

 

Does Medicare cover flu shots ?

 

If you use a Medicare-enrolled physician, or other qualified health care provider, and they accept assignment, Medicare Part B will cover one flu shot per season, and you will pay nothing.

There is also no deductible with pneumonia shots.

 

Why should the elderly get flu shots ?

 

Here are some concrete reasons why our elderly loved ones should get the flu vaccine.

Each year in the United States, 9 out of 10 flu-related deaths and 6 out of 10 flu-related hospital stays occur among people aged 65+. An annual flu shot is one of the best preventive measures to help protect against the flu. The shot is available in both a regular strength dose and a high dose that provides extra immunity, which is often recommended for older adults.

The source of the text is the NCOA Center for Benefits access – “Vaccines: What Medicare pays for” you can read it here.

The statistics above make a compelling argument for flu vaccination for the elderly community.

As you age, your immune system’s ability to defend your body against infections and viruses diminishes.

As a result, the older you are, if you come into contact with people who are infected, the more likely you are to catch the flu.

And to compound the problem further, the older you are, the more likely you are to develop serious complications from the flu, such as pneumonia.

Those elderly adults with certain underlying health conditions are at an even greater risk of serious complications.

 

The health conditions which put you at greater risk include –

 

  • asthma or COPD
  • heart disease
  • diabetes
  • liver or kidney disease
  • a compromised immune system

 

An immune system can be compromised by different types of cancer treatment, HIV/AIDS, steroids and other forms of anti-inflammatory treatments.

For all these reasons, it is important for the over 65’s to get the flu vaccination.

As the flu virus mutates and previous vaccines may no longer be effective the following season, you need to get a shot each too.

You are also protecting those around you when you are vaccinated, so it is important for the caregivers, the children and the grandchildren of elderly adults to also get the vaccine each year.

What are the different types of flu vaccine ?

 

The types of Influenza Vaccine for adults are –

 

  • Quadrivalent Influenza Vaccine 
  • High-Dose Flu Vaccine
  • Intradermal Influenza Vaccine
  • Adjuvanted Vaccine
  • Cell-based Flu Vaccine
  • Recombinant Flu Vaccines
  • Nasal Spray Vaccine

 

The Influenza Vaccines recommended for over 65’s are –

 

  • High-Dose Flu Vaccine
  • Adjuvanted Vaccine

 

You can read more about this on the Centers for Disease and Prevention website here.

 

Does Medicare cover the Shingles Vaccine ?

 

To be covered for the Shingles Vaccine, Shingrix, you have to be in a Medicare Part D plan –

 

  • the Shingrix Vaccine is recommended for adults over the age of 60 – Zostavax has been removed from the US since the 1st of July 2020
  • the amount to which your plan covers the Shingrix Vaccine will vary with each provider
  • the amounts of your co-pay will depend on your Medicare Part D plan
  • your Medicare Part D plan will have its own rules for administration, payment and network usage 

 

What is the Shingles Vaccine ?

 

Shingles is caused by the virus gives us chickenpox – the varicella-zoster virus.

If a person has had the chickenpox, the virus will lie inactive in nerve tissue near the spinal cord and brain. Many years in the future, the virus may reactivate as shingles.

Shingles is most common in over the 50s, and even more so in the over 80s.

You are also at greater risk of getting shingles if you have a compromised immune system. 

Shingles is a condition where the virus causes a rash which can appear on any part of your body, which will blister, becoming very painful to touch and can make movement very unpleasant.

My mom had shingles in her left eye when she 88, and it truly was a nightmare.

The pain was constant for months – about six I believe – and she was unable to do much other than rest or sleep.

Shingles may lead to long term nerve pain, numbness and tingling, long after you have recovered from the actual virus – this is called Neuralgia or Neuropathy.

 

Prior to July 2020 the two main Vaccines for shingles in the US were –

 

  • Zostavax
  • Shingrix

 

But Shingrix has been more successful in protecting people from getting shingles, so the 1st of July 2020 Zostavax was removed from sale in the US.

The CDC advises all the over 50s to get the Shingrix Vaccine for shingles.

To learn more about the Shingles vaccine, got to the Centers for Disease Control and Prevention website here.

Does Medicare cover Tetanus shots ?

 

If you have an illness or injury, Medicare Part B or Medicare Part C, will cover the Tetanus Vaccine as “medically necessary” if it is prescribed by a Medicare-enrolled doctor.

 

To be covered for the Tetanus Vaccine under normal circumstances for a booster, you have to be in a Medicare Part D plan –

 

  • the Tdap  and Td Vaccines are for tetanus, diphtheria and pertussis (whooping cough)
  • the amount of the Tdap or Td Vaccine coverage you have will vary according to the Medicare Part D plan that you have joined
  • your Medicare Part D plan will have its own rules for administration, for payment and for network use

 

What is the Tetanus Vaccine ?

 

Tetanus is an infection caused by a toxin made by spores of bacteria, Clostridium tetani, which, when they enter the body, develop into bacteria, and produce the toxin tetanospasmin.

The spores are found all around us, and can enter the body through breaks in the skin, such as puncture wounds from a nail or needle, or wounds which are contaminated with soil, dust or feces, as well as burns, insect bites, surgery, dental infections and more.

The most well-known symptom of tetanus is “lockjaw”, where the muscles of the jaw tighten, which can lead to problems with swallowing, muscles spasms, headache, fever, and far more serious complications which can ultimately lead to death.

For that reason, it is important to get the tetanus vaccine if you haven’t had it, and to get a booster once every ten years.

In the US, most small infants receive the vaccine for tetanus, along with one for diphtheria and another for pertussis, otherwise known as whooping cough.

This first vaccine for infants is known a DTaP and is spread over a series of inoculations over around 6 years.

5 years later, the child receives a booster vaccine called Tdap

Adults may receive the vaccine Tdap, or a version which contains no vaccine for whooping cough called Td.

The Center for Disease Control and Prevention (CDC) advises –

All adults who have never received one should get a shot of Tdap. This can be given at any time, regardless of when they last got Td. This should be followed by either a Td or Tdap shot every 10 years.

You can find the whole document on their website here.

The other sources for this passage on tetanus and the vaccines for tetanus were –

Mayo Clinic article on Tetanus, which you will find here.

A document on the Centers for Disease Control and Prevention (CDC) website which you will find here.

Which medical equipment and which supplies do Medicare pay for ?

 

The equipment and supplies covered by Original Medicare which is for use in the home is classified as  “durable medical equipment”, or as DME.

It is Medicare Part B, which covers DME for “use in the home”.

Those supplies and medical equipment which is used in a hospital are covered by Medicare Part A – hospital coverage.

 

Medicare classes equipment as Durable Medical Equipment if it is:-

 

  • Durable (can withstand repeated use)
  • Used for a medical reason
  • Not usually useful to someone who isn’t sick or injured
  • Used in your home
  • Generally has an expected lifetime of at least 3 years

 

Source: Medicare.gov website – here

Such “durable medical equipment”, or DME, which Medicare covers includes wheelchairs, crutches and walkers, hospital beds, respirators, patient lifts, and medical oxygen.

Do note that, durable medical equipment is only covered when it is medically necessary, as defined by Medicare.

Medicare will not typically cover items defined as convenience or comfort item, or which it sees as “not primarily medical in nature”, such as bath chairs, air purifiers, room heaters, grabbers, cold packs and massage devices.

That is not to say that Medicare will never cover an item which it lists as not covered. For if a doctor can make the case that a certain item may improve a patient’s condition, or make more expensive treatment unnecessary, Medicare may well decide to give coverage.

Medicare Part B’s typically will cover 80 % of the Medicare-approved price of DME, and you, the beneficiary, pay your coinsurance of 20% Medicare-approved price, and if it applies, your deductible.

 

Disposable medical supplies which are needed for use along with durable medical equipment in the home will generally be covered by Medicare Part B.

Disposable medical supplies though, which are not used in conjunction with durable medical equipment, will not usually be covered by Medicare Part B.

 

Examples of disposable supplies, which are not durable, not used in conjunction with a piece of durable medical equipment and not covered by Medicare Part B, include the following –

 

  • bandages
  • face masks
  • elastic stockings
  • pressure leotards
  • support hose
  • surgical leggings
  • disposable sheets
  • bags
  • fabric supports
  • incontinence pads

 

Medicare Part B may cover blood sugar strips and certain catheters, if they are used in conjunction with durable medical equipment,  or to treat long term health conditions.

Do note that some disposable supplies needed for home care will be covered if you receive the Medicare Home Health Care Benefit.

Free help with understanding Medicare

 

SHIP – State Health Insurance Assistance Programs

There is free guidance offered on Medicare, Medicaid and Medigap from all SHIPs.

If you want to contact your SHIP, you can find out how to do that here – “Free Help Understanding Medicare And Medicaid ? Here’s Where You Get It”. 

 

Does Medicaid cover pneumonia shots?

 

It is difficult to say exactly what coverage Medicaid gives for pneumonia shots, as each state is different, and the standards may vary.

This being said, pneumonia shots are offered to children who receive Medicaid, and in most states to adults on Medicaid as well.

Adults who are living in State Medicaid Institutions should be fully covered for the pneumonia shots.

The coverage for adults who receive Medicaid, but are not in institutions, is another question, as each state runs its own system, and there may, or may not be co-pays, and also the co-pays may vary.

 

To find your State Medicaid State Agency

 

To talk with, or to email someone in your State Medicaid Administration, you can find the info to contact your state Medicaid Agency here.

 

Step 1 –

Click the link to Medicaid.gov, look to the section I outlined in red.

 

 

Step 2 –

Just select your state and click on “GO” – it will take you to your State Medicaid Agency with all their contact information.

 

I’m Gareth and I’m the owner of Looking After Mom and Dad.com

I have been a caregiver for over 10 yrs and share all my tips here.

Gareth Williams

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