Dear Marci,

I have Medicare, and my doctor has recommended getting several vaccines in the coming year. How will Medicare cover these vaccines?

-Lorelai (Lancaster, PA)

Dear Lorelai,

Vaccines that you receive in an outpatient setting may be covered by Medicare Part B or Part D. Part D covers most vaccines that your doctor recommends you get, with a few exceptions (see below). Part D plans must include most commercially available vaccines on their formularies, including the vaccine for shingles (herpes zoster).
 
The amount you pay for your vaccine may vary depending on where you are vaccinated. Make sure to check your plan’s coverage rules and see where you can get your vaccine at the lowest cost. Typically, you will pay the least for your vaccinations at:

• In-network pharmacies
• A doctor’s office that
  • Coordinates with a pharmacy to bill your Part D plan for the entire cost of the vaccination process (the drug and its injection)
  • Or, can bill your plan directly for the vaccination process using an electronic billing system

When you are vaccinated in either of the above settings, you should only need to pay the plan’s approved coinsurance or copay for the drug and vaccination process. When you get a vaccine, ask the provider to call your Part D plan first to find out if your provider can bill your Part D plan directly. If this is possible, you should not have to pay the full out-of-pocket cost and later request reimbursement from your plan.

You may end up paying more for your vaccination if your provider:

• Cannot coordinate with a pharmacy to bill your Part D plan for the entire cost of the vaccination process (the drug and its injection)
• And/or, cannot bill your plan directly for the vaccination process using an electronic billing system

In these circumstances, your provider will bill you for the entire cost of the vaccination (the drug and its injection). You will have to pay the entire bill up front and request reimbursement from your Part D plan. It is important to know that your provider may charge you more than the Part D-approved amount for the vaccination, but your plan will only reimburse up to the approved amount—and you will not be refunded for any amount you pay the provider above the Part D-approved amount.

If you have Extra Help, the federal program that helps pay for some to most of the out-of-pocket costs of Medicare prescription drug coverage, you can go to any provider or in-network pharmacy to get vaccines. You will be covered for your vaccination and will only be responsible for the Extra Help copay. However, if you get your vaccine from a provider who does not directly bill your plan, you may need to pay the entire bill up front and then request reimbursement from your plan.

Part B covers the vaccines for the flu, pneumonia, and hepatitis B in the following situations:

• Flu: Part B covers one flu shot every flu season. The flu season runs from November through April. Depending on when you choose to get your flu shot, Medicare may cover a flu shot twice in one calendar year. For example, if you get a shot in January 2019 for the 2018/2019 flu season, you could get another shot in October 2019 for the 2019/2020 flu season.
• Pneumonia: Part B covers two separate pneumonia vaccines. Part B covers the first shot if you have never received Part B coverage for a pneumonia shot before. You are covered for a different, second vaccination one year after receiving the first shot. You are not required to provide a vaccination history when receiving the pneumonia vaccine. You can verbally tell the health care professional administering the shot if/when you have received past shots.
• Hepatitis B:  Medicare Part B covers the hepatitis B vaccine if you are at medium or high risk for hepatitis B (If you are at a low risk, the shot will be covered under Part D).

If you qualify for Part B coverage of a flu, pneumonia, or hepatitis B shot, Original Medicare covers these vaccinations at 100% of the Medicare-approved amount when you receive the service from a participating provider. This means you pay nothing (no deductible or coinsurance). Medicare Advantage Plans are required to cover these vaccines without applying deductibles, copayments, or coinsurance when you see an in-network provider and meet Medicare’s eligibility requirements for the service.
 
Part B also covers certain vaccines after you have been exposed to a dangerous virus or disease. For example, Part B will cover a tetanus shot if you step on a rusty nail, or a rabies shot if you are bitten by a dog. Original Medicare covers 80% of the Medicare approved amount for these vaccines after you meet the Part B deductible, and you will be responsible for a 20% coinsurance charge. If you have a Medicare Advantage Plan, contact your plan to learn about the cost-sharing for vaccines like these.
 
-Marci

As an adult, regular physical activity is one of the most important things you can do for your health. It can prevent many of the health problems that seem to come with age. It also helps your muscles grow stronger so you can keep doing your day-to-day activities without becoming dependent on others.

Not doing any physical activity can be bad for you, no matter your age or health condition. Keep in mind, some physical activity is better than none at all. Your health benefits will also increase with the more physical activity that you do.

If you’re 65 years of age or older, are generally fit, and have no limiting health conditions here are some things that the Center for Disease Control says are healthy and helpful.

Do some aerobic exercise each week. Walking is the easiest way. At a moderate pace, 250 minutes a week is the reccomendation. That is a little over 35 minutes a day. At a vigorous pace only 75 minutes a week is needed. And you can do as little as 10 minutes at a time and still get the aerobic effect. The point is to get the heart rate up.

In addition to aerobic work, muscle work is also needed each week. This could be weight lifting, resistance bands, heavy gardening or yoga. To keep our muscles strong we need to place enough resistance on the muscles so that the next movement is hard.

The point is to have active bodies as we age. You can find a wide variety of ways to stay active and still enjoy the process. For more information on this subject go to http://cdc.gov.

Dear Marci, I read a news story about fraudulent durable medical equipment suppliers. Are Medicare beneficiaries at risk of medical equipment fraud? How can I identify fraud like this, and how can I protect myself from it? -Arnav (Edison, NJ) Dear Arnav, Medicare Part B covers durable medical equipment (DME), which is equipment that serves a medical purpose, is able to withstand repeated use, and is appropriate for use in the home. There have been many recent reported instances of DME fraud, errors, and abuse, so it is important to recognize what DME fraud might look like. Some examples of DME fraud might include:Someone uses a fraudulent physician’s identity, or a physician’s stolen identity, to medically certify that you need DME.Someone steals your Medicare number and uses it to bill Medicare for a service that you do not need and/or was never delivered.Someone offers you a meal or food in exchange for your Medicare number.Someone calls you or visits your home to offer you “free” equipment that you do not need and then bills Medicare for the equipment.A DME supplier bills Medicare for more expensive DME than the equipment provided.A DME supplier continues to bill Medicare for rental payments for your DME after it has been returned.To protect yourself from DME fraud, errors, and abuse, learn the coverage rules about Medicare’s coverage of DME. Medicare will not cover DME unless your doctor has certified that you need it. There must also be documentation in your medical record supporting your medical need for the equipment or supplies. If you do need DME, ask your doctor about whether you meet the coverage requirements to get it. If you do, get your DME from a supplier that accepts Medicare assignment or, if you have a Medicare Advantage Plan, from an in-network supplier. Be aware of aggressive marketing that tries to persuade you to change DME suppliers. Before making a decision to change suppliers, speak with your doctor and your current supplier to see if there is a need for you to change. Do not respond to ads that offer “free” equipment to Medicare beneficiaries, be skeptical of offers that seem too good to be true, and do not give any personal information to someone who calls offering DME that you did not ask for. Protect your Medicare number. Only give your Medicare number to your doctor and other providers. Be careful when others ask for your Medicare number or offer free services as long as you provide your Medicare number. Check your Medicare Summary Notices (MSNs) if you have Original Medicare, or your Explanations of Benefits (EOBs) of you have a Medicare Advantage Plan, and billing statements regularly. Carefully look for any suspicious charges or errors. Also, remember that providers are not permitted to routinely waive cost-sharing or offer gifts or financial incentives for you to receive services from them. If you see any suspicious charges or have any reason to believe your provider is inappropriately billing Medicare for DME, call your provider to see if they have made a billing error. If you suspect a health care provider of DME fraud, contact your Senior Medicare Patrol (SMP) by calling 877-808-2468 or visiting www.smpresource.org. Your SMP can help identify Medicare fraud, errors, and abuse, and report them to the correct authorities. -Marci

May is Skin Cancer Awareness Month. According to the Skin Cancer Foundation, skin cancer is the most common cancer in the United States, but is also one of the most preventable forms of cancer. The following prevention tipscan help protect you:Seek the shade, especially between the hours of 10 a.m. and 4 p.m.Avoid tanning and never use UV tanning bedsCover up with clothing, including a broad-brimmed hat and UV-blocking sunglasses.Use a broad-spectrum (UVA/UVB) sunscreen with an SPF of 15 or higher every day. For extended outdoor activity, use a water-resistant, broad spectrum (UVA/UVB) sunscreen with an SPF of 30 or higher.Apply one ounce (2 tablespoons) of sunscreen to your entire body 30 minutes before going outside. Reapply every two hours or after swimming or excessive sweatingKeep newborns out of the sun. Sunscreens should be used on babies over the age of six months.Examine your skin head-to-toe every month.See a dermatologist at least once a year for a professional skin exam.

Last week, Medicare Rights President Fred Riccardi participated in an event hosted by The Atlantic called, “The State of Care: Future of Medicare.” Fred joined a panel discussion with Tricia Neuman of Kaiser Family Foundation and Zirui Song of Harvard Medical School about putting patients first and providing them with tools to make informed medical decisions. Watch the segment with below.    Watch the entire event here.

Dear Marci is a biweekly e-newsletter designed to keep you — people with Medicare, social workers, health care providers and other professionals — in the loop about health care benefits, rights and options for older Americans and people with disabilities. For reprint rights, please contact Mitchell Clark The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs and public policy initiatives.

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