14 Diseases You Almost Forgot About (Thanks to Vaccines)

Get Your Medicare Vaccinations At The Right Place Or Prepare To Pay

When it comes to Medicare, it matters whether you get your vaccinations at a pharmacy or at a ... [+] doctor's office.

getty

Medicare has a notorious history of not treating vaccinations equally. Here's an example from Ed, one of my clients.

My physician's office contacted me because I was due for my DTaP (diphtheria, tetanus, and pertussis) booster. I made an appointment. Then, I got the vaccine and a bill for $148 ($101 vaccine and $47 administration).

What's going on? I never got bills for flu or pneumonia shots from my doctor's nurse.

Medicare Part B, medical insurance, covers flu and pneumonia vaccinations with no deductible or copayment. When COVID crashed into the world, Part B paid for that, too. Medicare also covers the Hepatitis B vaccine for those at medium or high risk and vaccines directly related to an injury, such as tetanus, or direct exposure to a disease or condition, including rabies or botulism.

Then, all the other vaccines that seniors need to stay healthy are not covered under Part B. At the top of the list is shingles, followed by Hepatitis B to non-high-risk individuals, and DTaP, to name a few. The Centers for Medicare and Medicaid Services (CMS) requires Part D prescription drug plans to provide access to those and they all were subject to any deductible and cost sharing. For example, once meeting the plan's deductible (maximum of $485 in 2022), there was a copayment for each shingles shot, around $200, definitely unequal treatment of Part D vaccinations.

Thankfully, as of January 1, 2023, Medicare is treating all vaccines the same when it comes to cost sharing. Part D vaccinations are not subject to a deductible and there is no copayment or coinsurance.

Costs may be equal, but administration is still treated differently

Medicare beneficiaries can get Part B vaccinations in a physician's office or a pharmacy. If you have Original Medicare, any doctor or pharmacy that accepts Medicare assignment can provide the vaccination. If you elected Medicare Advantage, you should visit a doctor or pharmacy in the plan's network. Show up, present the necessary insurance card(s) and you're done.

It doesn't work the same way for Part D vaccinations, as Ed learned. He asked why his physician's office was a problem. Part D covers drugs from in-network providers. CMS considers physicians' offices as out-of-network. That's because Part D networks are defined as pharmacy networks only.

Then he asked about the bill, something he didn't see with his other vaccinations. (The bill includes the costs associated with Part D vaccines including the vaccine ingredient cost, a dispensing fee (if applicable), and an administration fee.) Ed called Medicare, his supplement insurance company, and finally, his Part D drug plan. He learned that, since the shot was administered out-of-network, he must pay the physician's bill and then submit the drug plan's form for reimbursement. The form asks for information that Ed wouldn't have, such as the NPI (National Provider ID) for the physician and the national drug code (the FDA's identifier). He has to contact his physician's office for help.

Will Ed and others ever be able to get all vaccines from their doctors? About 15 years ago, when the first shingles vaccine, Zostavax, appeared, a MLN Matters transmittal noted, "Requiring the beneficiary to pay the physician's full charge for a vaccine out of pocket first and be reimbursed by the plan later is not an optimal solution." CMS encouraged doctors to submit claims for Part D vaccinations using a web-based portal and agree to accept the plan's payment as payment in full. Based on the questions I get, that's still a work in progress.

I found several plans' reimbursement forms online. Buried somewhere, you'll likely find a sentence or two that claims are subject to the plan's provisions; in other words, the amount the plan would have paid for vaccination at a pharmacy. There's a chance that the reimbursement plan members get may be less than the amount paid to the physicians' offices.

Skip the hassle and bills

The next time you need a Part D vaccine, such as the new RSV (Respiratory Syncytial Virus), visit a pharmacy in your plan's network. You won't get a bill or have to submit a claim.

Ed learned his lesson. Next time, he'll visit a network pharmacy.

Check out my website or some of my other work here. 

Allergic Reaction To DTaP Vaccine Persists In Children

It is a must for every child to be vaccinated against diphtheria-tetanus-pertussis. The fifth and last vaccine (DTaP) given to children causes a red splotch to develop on the area.

This reaction can last a few days and the problem is that neither of two common drugs--ibuprofen (Advil) and acetaminophen (Tylenol)--help prevent this side effect. A Group Health Cooperative study appearing in the March issue of Paediatrics features this report.

Lisa A. Jackson, MD, MPH, a senior investigator at Group Health's Center for Health Studies and the study's lead investigator said, "Often children don't notice they have it. But it can concern parents, leading to medical visits or even needless antibiotic treatment, so we'd like to make it rarer."

372 children from 4 to 6 years old who were due for their fifth DTaP dose after getting 4 doses of this vaccine since age 2 months were observed. Four in 10 children were randomly assigned to receive ibuprofen; 4 in 10, acetaminophen; and 2 in 10, placebo.

The medication was given preventively 3 times: at 2 hours before, and 6 and 12 hours after, the vaccination. About a third of each group had local reactions at least 2 inches wide. The placebo and treatment groups did not differ significantly in their proportions of children whose reactions lasted at least 3 days or whose vaccinated limb swelled by about 1 inch or more.

As an explanation by Jackson, "Acetaminophen is an effective anti-pyretic (fever reducer). But it isn't an anti-inflammatory (inflammation reducer). We certainly thought that ibuprofen, through its anti-inflammatory effect, might make the local reactions less common or severe. We all want to decrease discomfort in children, so we were disappointed not to show a prevention effect for ibuprofen; but on the other hand we got a fairly definitive answer, and that's why we do research."

The acellular vaccine, licensed in 1997, contains only those parts of the diphtheria (whooping cough) bacteria that are critical to providing immunity. The previous version--whole cellular DTP vaccine--contained whole bacteria. The newer acellular shot results in less fever in 2- and 4-month-old babies than did the older whole-cell shot. This is significant because fever can lead to seizures--rare, but serious, adverse events associated with the DTP shot.

Spacing Out Child Vaccines

Should I space out my child's immunizations?

Tanya Altman, MD, FAAP

There isn't any evidence 'that spacing out vaccines is better than giving them according to the schedule that has been studied and tested for many years by the CDC. In fact, by spacing out your child's vaccines, what you are doing is leaving them vulnerable to these diseases at a time when they can get really sick when they are so young. There is a reason that we vaccinate babies at two months, at four months, at six months of age. It's because that's when if they were to catch these illnesses, they can get very seriously ill and even die.

Narrator

Tell me more about the two, four, and six, why was that chosen?

Tanya Altman, MD, FAAP

That's a good question. Scientists have been studying vaccines for quite some time, and they are always improving them and making them better. And initially, they came up with this vaccination schedule, as to when the best time is to give vaccines to infants. And if you look at the schedule, you'll notice that there are several booster doses. So for example, babies will get their first whooping cough vaccine. It's a combination of DTaP Diphtheria, Tetanus, and Pertussis, which is whooping cough at two months. And then at four months, when they get that booster vaccine, it protects them a little more. And then at six months, they get another booster, and they're protected even a little more. And then at 15 or 18 months, they will get that final booster to get them the best protection that we have until they need another dose before kindergarten. And all of these booster doses are important, because over time, immunity to certain diseases can wane, and so with each booster dose that you get, your body is generating more protection.

","publisher":"WebMD Video"} ]]>

Hide Video Transcript

Narrator

Should I space out my child's immunizations?

Tanya Altman, MD, FAAP

There isn't any evidence 'that spacing out vaccines is better than giving them according to the schedule that has been studied and tested for many years by the CDC. In fact, by spacing out your child's vaccines, what you are doing is leaving them vulnerable to these diseases at a time when they can get really sick when they are so young. There is a reason that we vaccinate babies at two months, at four months, at six months of age. It's because that's when if they were to catch these illnesses, they can get very seriously ill and even die.

Narrator

Tell me more about the two, four, and six, why was that chosen?

Tanya Altman, MD, FAAP

That's a good question. Scientists have been studying vaccines for quite some time, and they are always improving them and making them better. And initially, they came up with this vaccination schedule, as to when the best time is to give vaccines to infants. And if you look at the schedule, you'll notice that there are several booster doses. So for example, babies will get their first whooping cough vaccine. It's a combination of DTaP Diphtheria, Tetanus, and Pertussis, which is whooping cough at two months. And then at four months, when they get that booster vaccine, it protects them a little more. And then at six months, they get another booster, and they're protected even a little more. And then at 15 or 18 months, they will get that final booster to get them the best protection that we have until they need another dose before kindergarten. And all of these booster doses are important, because over time, immunity to certain diseases can wane, and so with each booster dose that you get, your body is generating more protection.

---