While we always recommend your patient check with their insurance plan before receiving a vaccination if they have any questions about coverage or co-payments, we do have a few pointers for vaccinating Medicare patients!
Medicare B vs. Medicare A or D
Medicare plans generally have several different Parts -- or "buckets" if you will -- which you may or may not see when looking at a Medicare insurance card. In fact, patients may have different "buckets" (or supplemental plans) through multiple companies!
Each Medicare part covers very specific things, but on a very high level, Medicare Part A covers hospital expenses; Medicare B covers preventative and/or outpatient medical expenses, which includes certain vaccines; and Medicare D covers prescription benefits, which includes certain other vaccines. There are other divisions within Medicare plans, but the VaxCare check-in system will only refer to Medicare Part B and D, so we've excluded the rest from this article.
When we say that TDAP is only covered by Medicare D benefits, or Prevnar is covered by Medicare B benefits, those aren't VaxCare rules. Medicare has determined which "bucket" of funds covers which vaccines, and VaxCare must abide by these requirements.
How will you know if my patient has a Medicare Advantage plan?
Our system checks insurance eligibility based on member IDs and group numbers. We have programmed our tools to recognize Medicare Advantage and Supplemental Medicare C plans under Anthem, Humana, or other major insurance providers, and the same rules about the "buckets" above generally apply to these patients as well.
How do I know which insurance is primary?
We usually recommend starting with a traditional, or federally-issued, Medicare card first. If the patient is carrying a standard Medicare B card, this is generally their primary. However, if the system shows this is not the primary insurance, ask the patient for another card. Many patients start with a standard Medicare plan and then later replace it with a Medicare Advantage plan through a major insurance company. The system will tell you if you need to enter a different member ID or primary insurance.
Please read and follow the instructions for the patient's eligibility response upon Check-In, or your patient will end up with a bill.
What happens if my patient doesn't have Part B or Part D?
If your patient does not have one of the "buckets" of Medicare, they are not eligible to receive Risk Free vaccines that are usually covered under those "buckets," because they have opted out of the coverage that would include those vaccines.
Medicare Part B (or an Advantage Plan that includes Part B, Medicare C):
Covers flu, Pneumovax, and Prevnar.
Medicare Part D (or an Advantage Plan that includes Part D):
Covers TDAP or Zoster (shingles) usually with a co-pay. Please carefully review our procedures for processing claims through this supplement.
Let's once again emphasize something very important:
If your patient does not have Part B or Part D coverage, they do not have insurance coverage for the vaccines covered by the corresponding Parts. For example, a patient with only Medicare Part A would not be Risk Free for vaccine coverage in an outpatient setting, because they have only elected to have Part A coverage. A patient who has Part A and Part B, but does not have Part D or an advantage plan, will not have TDAP coverage.
Vaccinating with Medicare Part B
We frequently get questions about whether or not Medicare B will cover certain vaccines in a given timeframe. Once again, I'll remind you that we always recommend the patient call their particular insurance plan to check coverage prior to vaccination if they have any questions. But generally speaking, Medicare B will cover one flu shot per season (quadrivalent or high dose is fine, as long as the patient is in age indication), and they will cover Prevnar and Pneumovax as long as one full year has passed between injections.
While Hepatitis B vaccines may be covered out of medical necessity, you must partner bill these vaccines, as we are only able to vaccinate within preventative parameters. We cannot, as a third party, provide the documentation necessary to have this vaccine covered under Medicare part B or Advantage plans.
The Scheduler will return the following message for all patients with an active Medicare B plan, reminding you up front that patients with Medicare B are only eligible for flu, Pneumovax, and Prevnar in an outpatient setting.
Again, this is Medicare's rule, not VaxCare's. The eligibility response does not tell you if the patient has already had these vaccines in the given timeframe, however, so be sure to check with the patient before vaccinating.
Vaccinating with Medicare Part D
If a patient also has Medicare Part D, the Scheduler will return a second response, indicated by the message below.
If a copay is returned when this button is clicked, this means the patient has Medicare Part D, and the system will show you the copays associated with any vaccines their particular Medicare Part D will cover, namely TDAP and Zoster (shingles) if the Medicare D check is run on the date of service.
The copays are real-time and based on a query we run behind the scenes to a company called TransactRX, which correspond to the patient's tier of Med D into which they have opted. You must collect copays by entering a credit or debit card in the pop-up box that appears when you return copay information to be eligible for a risk free encounter.
Once you enter an active method of payment, the message will display "Credit Card collected - consent form required for risk free." Medicare copays cannot be paid with cash. VaxCare will charge the card this amount if the consent form is printed with copay amounts displayed, the patient signs, and the consent is returned via our secure uploader or fax within 25 days of the DOS. Once the consent has been received, the encounter will move from "Pending" to "Processing" on your Billing > Transactions tab.
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