If you are on Medicare, or soon to be, you will want to become familiar with the following statement which comes directly from the www.medicare.gov website.
Your doctor or other health care provider may recommend you get services more often than Medicare covers. Or, they may recommend services that Medicare doesn’t cover. If this happens, you may have to pay some or all of the costs. It’s important to ask questions so you understand why your doctor is recommending certain services and whether Medicare will pay for them.
It is important to keep this in mind each and every time you visit the doctor so that you are not caught off guard. If you are on Medicare and Medicare does not approve a service, your supplement will not cover it because the supplement is your secondary coverage and is only intended to pay your cost sharing after Medicare has paid first. If you have a Medicare Advantage plan, (claims go straight to the insurance company), your insurance carrier will likely deny the claim. In the end, the responsibility to pay the bill will fall on your shoulders.
A good example is tetanus shots. Most physicians suggest updating your tetanus vaccine every ten years. Upon going to the doctor for a check-up, if they see in your records that you haven’t had one in ten or more years, most physicians will bring it to your attention and offer to do it in their office that same day. You will then receive the bill because Medicare will only cover the tetanus shot in the event it is needed, for example, if you stepped on a rusty nail. However, if you are just following your doctor’s advice and choose to have the shot, Medicare will consider it “elective” and will not pay for it.
In addition, shots and vaccines are covered differently by Medicare depending on which one you are having.
Preventative vaccines such as Flu shots, Pneumonia and Hepatitis B are covered under Part B Medicare (Hepatitis B only if you are medium to high risk based on health history). When covered through Part B, you may have some cost sharing depending on which type of coverage you have, be it a Medicare Advantage plan or original Medicare paired with a Medigap plan. If you are unsure, check with your agent and they will be able to provide details about your coverage.
All other vaccines, such as the shingles (herpes zoster) are covered under Medicare Part D prescription coverage. You will want to check the coverage rules under your Part D plan to find out where you should get the shot so that you are getting it for the lowest possible cost. Again, you will want to check with your agent who will be able to provide this information for you.
At the end of the day, it is important to understand the following: Just because your doctor is suggesting a test or a shot, do not assume it is covered by Medicare. It is perfectly acceptable to ask your doctor if it will be covered, at which time he may refer you to the billing department of his office. That said, you may not feel comfortable challenging your doctor every time he recommends a service. A good rule of thumb is if you are sick or injured, Medicare will cover your medical expenses. Otherwise, refer back to the statement from the Medicare website in the beginning of this article and verify coverage before you commit to the service.