Dear Marci,

I called my pharmacy to schedule an appointment to get my flu vaccine. They told me I could also schedule my RSV vaccine, which was news to me. Does Medicare cover this?

-Matteo (St. Louis, MO)

Dear Matteo,

What a timely question! Earlier this year, the Food and Drug Administration (FDA) approved the RSV vaccine. According to the Centers for Disease Control and Prevention, the RSV vaccine can help prevent lower respiratory tract disease caused by respiratory syncytial virus (RSV). RSV season varies from year to year, but usually starts in the fall and peaks in the winter. RSV can affect people of all ages but may be especially serious for infants and older adults.

Medicare Part D covers the RSV vaccine if it’s recommended for you by the Advisory Committee on Immunization Practices (ACIP), a government agency that gives advice about who should get certain vaccines. At this time, the RSV vaccine is recommended for adults over the age of 60.

There should be no cost to you to get this vaccine. This means your pharmacy shouldn’t charge you a copay or deductible to get the RSV vaccine. If you have Medicare Part D, it should be free to you.

If you have Medicare Part D and your doctor or pharmacy tries to charge you for the RSV vaccine, you should call 1-800-MEDICARE (1-800-633-4227) for help.

If you have non-Medicare drug coverage (like drug coverage from an employer or union), you should check to see its coverage rules for the RSV vaccine. Because this is a newer vaccine, it may not be listed on an insurance plan’s list of covered drugs yet, so you should check with your plan before making an appointment.

Remember that while the RSV vaccine is covered by Part D, your flu and COVID-19 vaccines will still be covered by Part B.

I hope this helps!

-Marci

Health Tip
According to the Centers for Disease Control and Prevention (CDC), it is important to be able to recognize a stroke quickly, since fast treatment can lessen the brain damage that stroke can cause. By knowing the signs and symptoms of a stroke, you can take quick action and possibly save a life. If you believe someone might be having a stroke, remember the acronym F.A.S.T. to perform a simple test for stroke symptoms:

Face: Ask the person to smile. Does one side of their face droop?
Arms: Ask the person to raise both arms. Does one arm drift downward?
Speech: Ask the person to repeat a simple phrase. Is the speech slurred or strange?

Dear Marci,

I have Original Medicare and a Medigap but have been seeing a lot of ads for Medicare Advantage Plans that seem great. I don’t want to fall for just good marketing, though. Are Medicare Advantage Plans better than Original Medicare? How should I choose?

-Colette (Cincinnati, OH)

Dear Colette,

It’s great that you are taking the time to learn about your options before enrolling in a plan. There are many important choices to make about your health care coverage, and being informed can help you make the best decisions for your own needs.

People with Medicare can get their health coverage through either Original Medicare or a Medicare Advantage Plan (also known as a Medicare private health plan or Part C). While there are many differences between the two, remember that Medicare Advantage Plans must provide the same benefits offered by Original Medicare, but may apply different rules, costs, and restrictions.

Let’s review some of the main differences between these two ways to get your Medicare:

Costs

Original Medicare: You will be charged for standardized Part A and Part B costs, including a monthly Part B premium. You are responsible for paying a 20% coinsurance for Medicare-covered services if you see a participating provider after meeting your deductible.
Medicare Advantage: Your cost-sharing varies depending on the plan. You usually pay a copayment for in-network care. Plans may charge a monthly premium in addition to the Part B premium.
Supplemental insurance
Original Medicare: You have the choice to pay an additional premium for a Medigap policy to cover Medicare cost-sharing.
Medicare Advantage: You cannot purchase a Medigap policy.
Provider access
Original Medicare: You can see any provider and use any facility that accepts Medicare (participating and non-participating).
Medicare Advantage: You can typically only see in-network providers.
Referrals
Original Medicare: You do not need referrals for specialists.
Medicare Advantage: You typically need referrals for specialists.
Drug coverage
Original Medicare: You must sign up for a stand-alone Part D plan if you want prescription drug coverage.
Medicare Advantage: In most cases, the plan provides prescription drug coverage (you may be required to pay a higher premium).
Other benefits
Original Medicare: Does not cover vision, hearing, or dental services.
Medicare Advantage: May cover additional services, including vision, hearing, and/or dental (additional benefits may increase your premium and/or other out-of-pocket costs).
Out-of-pocket limit
Original Medicare: No out-of-pocket limit.
Medicare Advantage: Annual out-of-pocket limit. Plan pays the full cost of your care after you reach the limit.

Between the two options, one is not better than the other for everyone. Medicare Advantage and Original Medicare are just different, and you may prefer one over the other depending on your needs and priorities.

Because you have a Medigap, I do want you to note that if you switch from Original Medicare to Medicare Advantage, you will lose your Medigap. Depending on your state’s Medigap enrollment rules, it may be difficult or expensive to purchase a Medigap later. There are only a few specific protected times to purchase a Medigap under federal rules, but your state may offer additional rights.

To receive individualized counseling on your options, I recommend calling your local State Health Insurance Assistance Program (SHIP). I hope this helps!

-Marci

Dear Marci,

I’m enrolling in Medicare soon and am confused about Medigaps. Can you explain what these are?

-Julia (New York, NY)

Dear Julia,

Medigaps are health insurance policies that offer standardized benefits to work with Original Medicare (not with Medicare Advantage). They are sold by private insurance companies. If you have a Medigap, it pays part or all of certain remaining costs after Original Medicare pays first. Medigaps may cover outstanding deductibles, coinsurance, and copayments. Medigaps may also cover health care costs that Medicare does not cover at all, like care received when travelling abroad. Remember, Medigaps only work with Original Medicare. If you have a Medicare Advantage Plan, you cannot buy a Medigap.

Depending on where you live and when you became eligible for Medicare, you have up to 10 different Medigap policies to choose from: A, B, C, D, F, G, K, L, M, and N. Note that policies in Wisconsin, Massachusetts, and Minnesota have different names. Each policy offers a different set of standardized benefits, meaning that policies with the same letter name offer the same benefits. However, premiums can vary from company to company.

Before you buy a Medigap policy, be sure to do your research. Some steps you may wish to take include the following:

Make sure you are eligible to purchase a Medigap. Remember that you can only have a Medigap if you have Original Medicare. There may be other Medigap eligibility requirements that apply to you, depending on the state in which you live.
Learn when you have the right to buy a Medigap without restriction. There are federal protections for people over 65 to buy a Medigap in certain situations. Some states have additional protections for individuals under 65 or during other times.
Compare the different types of policies that exist. As mentioned above, there are 10 different standardized policies in most states, each covering a different range of Medicare cost-sharing.
Learn how a Medigap covers prior medical conditions to know if any of your medical costs may be excluded from Medigap coverage. Depending on your circumstances, a Medigap can exclude coverage for prior medical conditions for a limited amount of time.
Find out how Medigap premiums are priced so you can make cost comparisons. It is important to understand the ways that insurers set premiums to find the best deal for you.
Have a list of questions to ask when shopping for a Medigap to remind you what you should consider. Buying a Medigap can be complicated, but using a set of written questions and asking for help when needed can help you stay organized and simplify the process.
Over the next few weeks, we’ll take a deeper dive into when you can purchase a Medigap and how to compare your options. I hope this helps!

-Marci