Marci's Medicare AnswersAugust 2012
Dear Marci,
My doctor told me that I need to get the shingles vaccine and that my Medicare Part D plan should cover it. If that’s true, what will I pay for it?
—Walter
Dear Walter,
If you have a Medicare Part D plan, it must cover your shingles shot. How much you pay will depend on where you get the shot. You will typically pay the least for your shingles shot if you are vaccinated at:
- a pharmacy that is in your drug plan’s network (an “in-network” pharmacy); or
- a doctor’s office that
- can work with a pharmacy that will bill your Part D plan for the entire cost of the vaccination process; or
- can bill your plan for the vaccine directly using a special computer billing system called Dispensing Solutions.
If you receive the shot from an in-network pharmacy or from a doctor that can bill your Part D plan, you should only need to pay the plan’s approved copay at the time you get vaccinated.
However, you will typically need to pay more for the shingles vaccine if you get it from a doctor who cannot bill your plan for it. In this case, you will have to pay the entire cost of the vaccination up front and then follow your Part D plan's rules to get a refund. When you are reimbursed by the plan, you will only be reimbursed for your Part D plan’s approved payment. Keep in mind that you will be responsible for the difference between the doctor’s charge and the plan’s approved payment.
If you have Extra Help, the program that helps pay for your prescription drugs, you can go to any doctor or in-network pharmacy. Your vaccination will be covered and you will only be responsible for the Extra Help copay. Keep in mind that you may need to pay the entire bill up front and then be reimbursed by your Part D plan, if you get vaccinated by a provider who does not directly bill your Part D plan.
Don’t forget that it’s important for you to check with your Part D plan before you get the shingles shot, so that you can find out how to get it covered at the lowest cost.
—Marci
Dear Marci,
I was told by my doctor that I might be considered a hospital outpatient, as opposed to a hospital inpatient. What’s the difference, and what does this have to do with Medicare?
—Norman
Dear Norman,
Generally, an outpatient hospital service is any type of medical care you receive at a hospital that your doctor does not expect will require an overnight stay. However, in some cases, you might stay overnight at a hospital and still be considered an outpatient. To be considered a hospital inpatient, you need to be formally admitted to the hospital.
The difference in your hospital status can affect your Medicare coverage for other services. For example, Medicare will only cover your stay in a skilled nursing facility (SNF) if you have spent at least three consecutive days as a hospital inpatient. Inpatient hospital services, like SNF stays, are generally covered under Medicare Part A, while outpatient services are usually covered under Medicare Part B.
Emergency room services or outpatient clinic services, such as same-day surgery, are generally considered outpatient services. Check with your doctor to see if you are an outpatient or inpatient, since this difference can affect the way Medicare covers the health care services you receive.
—Marci
Dear Marci,
I went to pick up my medications at the pharmacy the other day, but I couldn’t afford the expensive copayments. I was told I have Extra Help, but my pharmacist is telling me I owe a lot of money for my medications. What can I do to get my drugs?
—Rob
Dear Rob,
If you have Extra Help and a Part D plan, you can present Best Available Evidence (BAE) to your pharmacist to get your medications at the copayments offered under Extra Help. Your Extra Help status may be incorrectly reflected in either your plan or pharmacy’s system. If you show your pharmacist your Medicaid card, Social Security Administration award letter indicating your Extra Help status, or Medicare Savings Program Notice of Award letter, the pharmacy should only charge you the Extra Help copayments for your medications. Your plan should update your Extra Help status in its system within 48 to 72 hours so you can access your medications with Extra Help copayments the next time you fill a prescription. If you cannot find proof that you have Extra Help, your plan must work with Medicare to investigate whether you have the Extra Help benefit.
—Marci
Marci’s Medicare Answers is a service of the Medicare Rights Center (www.medicarerights.org), the nation’s largest independent source of information and assistance for people with Medicare. To subscribe to “Dear Marci,” MRC’s free educational e-newsletter, click here.
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