Does Medicare Cover Pneumonia Shots?Read our guide to find out what Medicare pays for pneumonia shots.
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Contracting pneumonia is a big worry for older people because it can lead to extended hospital stays and more health complications.
Thankfully, if you’ve signed up for Medicare, you’ll be able to get a pneumonia shot (pneumococcal vaccine) to lower the chances of contracting this lung infection.
Read our guide to understand how Medicare covers pneumococcal vaccines and whether or not you should get one when you visit your doctor.
What Is Medicare?
Medicare is a federal health program for people over the age of 65, disabled individuals of any age, and those who suffer from ESRD (End-stage Renal Disease) and ALS (Lou Gehrig’s).
There are two types of coverage Medicare beneficiaries can receive, Original Medicare and Medicare Advantage.
Original Medicare is the government-run program that covers Part A (hospital insurance) and Part B (general medical insurance).
Medicare Advantage is private health insurance that covers both Part A and Part B for its members.
Both types of coverage have monthly costs, deductibles, coinsurance, and co-payments that members need to pay in order to be covered.
There’s also Medicare Part D which deals with at-home, self-administered prescription medication.
Terms You Should Know:
Monthly premiums: These are fees you must pay each month to be a Medicare beneficiary.
With Medicare Advantage, plans usually charge their members an additional premium on top of the Medicare Part A and B premium.
Deductibles: These are costs that you’ll need to cover before your insurance starts to pay for your medical expenses.
Coinsurance: This is the portion of costs that Medicare beneficiaries must pay for their treatment. Medicare or their Medicare Advantage provider will cover the rest of the cost.
Co-pays or co-payments: In some cases, Medicare beneficiaries will pay set amounts for certain services, tests, and treatments. These are known as co-pays and can range from a couple of dollars to a few hundred dollars depending on the service.
What Is a Pneumonia Shot?
Pneumonia is an infection of the lungs that can be caused by a variety of different microbes, including bacteria, viruses, and fungi.
It can be a serious illness, especially for young children, the elderly, and people with weakened immune systems.
Symptoms of pneumonia include coughing, chest pain, shortness of breath, rapid breathing, sweating, and fever.
Treatment typically involves antibiotics to kill the bacteria causing the infection, as well as rest and plenty of fluids.
The pneumonia shot or pneumococcal vaccine is a vaccine that helps protect against this disease.
The pneumococcal vaccination is recommended for all adults over the age of 65, as well as for people of any age who have certain medical conditions that put them at risk for pneumonia. It is usually given in two doses, with the second dose given after 5 years.
Where Can I Get a Pneumonia Shot?
Vaccines for illnesses such as pneumonia and shingles are widely available across the country. You can generally get a pneumonia shot at pharmacies, doctors' offices, clinics, or hospitals.
Types of Pneumonia Vaccines
There are two types of pneumonia vaccines that are approved by the FDA in the U.S.—Prevnar 13 and Pneumovax 23. Both of these vaccines are considered to be safe and effective and are available to all Medicare beneficiaries in the U.S.
Prevnar 13 is a pneumococcal vaccination that helps give protection against 13 types of bacteria that cause pneumonia.
It is recommended for all adults over the age of 65, as well as for children under the age of 5. The vaccine is given in a series of shots, with the first dose given at 2 months of age, followed by booster shots at 4, 6, and 12 months.
Pneumovax 23 is another pneumococcal conjugate vaccine that helps protect against these pneumonia-causing bacteria. The vaccine works by stimulating the body's immune system to produce antibodies that recognize and attack the bacteria if it enters the lungs.
Pneumovax 23 is recommended for adults 65 years of age or older, as well as for people of any age who have certain medical conditions that put them at increased risk for pneumococcal pneumonia.
If you have any concerns about taking either Prevnar 13 or Pneumovax 23, speak to your doctor or pharmacist and get your questions answered.
Will Medicare Cover Pneumonia Shots?
Yes, Medicare will cover 100% of the cost of pneumonia shots under Medicare Part B. This means that you won’t need to pay anything if you ever need to get one.
Pneumonia shots are considered to be preventive treatment by the Center for Medicare and Medicaid Services (CMS). You will also be able to get other types of vaccinations or shots for flu.
What Is Medicare Part B?
Medicare Part B is outpatient care or general cover for medical expenses while Medicare Part A is inpatient or hospital treatment.
Medicare Part B also covers preventative services, tests, and treatments. This includes two pneumonia shots.
If you’d like to learn more about Medicare Part B, be sure to read our guide.
If you decide to get a pneumococcal vaccine or your doctor recommends it, you won’t have to pay any coinsurance or co-payment. However, you will need to pay your annual Part B deductible, which is $233 in 2022.
Another crucial point is that your doctor will need to accept Medicare assignment. This means they agree to the rates paid by the CMS for services rendered.
If your doctor does not accept assignment, Medicare will only pay up to their coverage amount and you will need to pay the difference.
For example, let’s say that the Medicare assignment is $100, but your doctor, who doesn’t accept assignment, charges $115. In this case, you’ll need to pay the $15 difference between the Medicare-covered amount and what your doctor charges.
Do I Need a Pneumonia Shot?
If you are over the age of 65 or immuno-compromised then getting a pneumonia shot is an effective method of preventing lung infections as you age.
Our advice is that you speak to your doctor about the benefits and drawbacks of getting regular pneumonia and flu shots as you get older.
Will Medicare Advantage Cover Pneumonia Shots?
Yes, if you have Medicare Advantage you will be covered for pneumococcal vaccines and other shots that Medicare covers.
Medicare Advantage Plans are required to provide the same level of coverage to Medicare beneficiaries as they would have if they were members of Original Medicare.
However, keep in mind that your Medicare Advantage Plan might have a preferred network of doctors or physicians that they use. You might be required to use one of your plan’s in-network providers to be covered by your Medicare Advantage health plan.
Are Pneumonia Vaccines Safe?
Yes, both Prevnar 13 and Pneumovax 23 have been thoroughly tested by the FDA. They are both considered to be safe and effective as preventative treatments for pneumonia-causing bacteria.
However, while it is not possible for you to contract pneumonia from getting either Prevnar 13 or Pneumovax 23, you may experience side effects. These side effects will generally pass within a couple of days.
It’s important to discuss this with your doctor so that you understand what to look out for when you get your shot.
Will Medicare Supplement (Medigap) Insurance Help Pay for Pneumonia Shots?
Medicare Supplement Insurance is an additional type of health insurance that helps to pay for out-of-pocket costs that Original Medicare doesn’t cover, such as coinsurance, deductibles, and co-payments.
While Medigap won’t help you pay for pneumonia shots, it may help you cover some of the other costs associated with your coverage, like assistance with paying your Part B deductible.
Remember that you can only get Medicare Supplement Insurance if you have Original Medicare. You cannot buy Medigap cover if you are a member of a Medicare Advantage Plan or Prescription Drug Plan (Part D).
Which Vaccines Does Medicare Cover?
Medicare covers the following vaccines:
The Flu vaccine.
The Pneumonia vaccine.
The Hepatitis B vaccine.
If you have a Medicare Advantage Plan or Part D Plan, you will be covered for the vaccines we’ve already mentioned and you’ll also be covered for:
The Shingles vaccine.
The Tdap vaccine (tetanus, diphtheria, and pertussis).
Any other vaccine that is deemed to be medically necessary to prevent an illness, but is not covered by Medicare Part B.
If the vaccine you’re receiving is covered under Medicare Part B, you won’t have to pay any money when you get them.
If you get a vaccine that is covered by Medicare Advantage or a Part D Prescription Drug Plan, you might have to pay a co-payment or coinsurance cost. This will depend on the type of plan you have and may only be a couple of dollars.
FAQs about Medicare and Pneumonia Vaccines
Are pneumonia shots covered by Medicare Part B?
Yes, Medicare Part B covers both FDA-approved pneumonia shots Prevnar 13 and Pneumovax 23. If you're a Medicare beneficiary, you won't have to pay anything if you get either vaccine.
How much does Medicare reimburse for pneumonia vaccines?
Medicare will reimburse you 100% of the Medicare-approved amount for your pneumonia vaccine if you are enrolled in Medicare Part B. If you only have Medicare Part A coverage, you will have to pay for the cost out-of-pocket.
Does Medicare pay for pneumonia and shingles vaccines?
Yes, Medicare Part B will cover the costs of pneumonia vaccines if you are enrolled for Part B coverage. If you have Medicare Advantage with prescription drug coverage, you can get some or all of the cost of the shingles vaccine covered.
Does Medicare pay for pneumonia shots at a pharmacy?
Yes, if you are a Medicare Part B beneficiary and go to a pharmacy that accepts Medicare assignment, Medicare will pay for the cost of your pneumonia shot.
Where Can I Learn More about Medicare Coverage?
Pneumonia shots are an important consideration if you are over the age of 65 and don’t want to get a lung infection. Thankfully, if you are enrolled in Part B, you’ll be fully covered for both types of pneumonia vaccines.
If you’re interested in finding out about what Medicare will cover, how to enroll, what costs are associated with enrolling, and how to find a great Medicare Advantage Plan in your area, read our Medicare hub articles for more information.