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COVID-19 has changed healthcare in the United States and around the world. Medicare, in particular, has adapted to the pandemic by increasing access to testing, treatments, and preventive measures like vaccines. Unfortunately, that coverage is not all-inclusive and some people may not be able to access all the services they need or want.
That is especially true when it comes to vaccines. In response to new variants and the availability of different vaccines, CDC guidelines continue to evolve. It can be a challenge to keep up with all the changes!
This FAQ will address what vaccines are available to you, when you can get them, how many doses you can get, and what they will cost.
Medicare covers the primary series for vaccines that have been vetted by the FDA. At this time, there are four vaccines available for use in the United States. The Pfizer and Moderna vaccines have been granted full FDA approval. The Johnson & Johnson (Janssen) and the Novavax vaccine remain under an emergency use authorization.
It is important to understand what constitutes a primary series. For most Americans, the Pfizer, Moderna and Novavax vaccines are given as two doses separated by three to four weeks. The Johnson & Johnson vaccine is given as a single dose.
Some people may not be able to mount an adequate immune response with the traditional primary series. It could be they are immunocompromised from a medical condition or from medications they take. In those cases, they may be eligible for an extra dose in their primary vaccine series.
A third dose of the Pfizer or Moderna vaccine can be administered within 28 days for the two-dose series and is covered by Medicare. For anyone who is immunocompromised, this is considered part of the primary series and is not a booster dose.
The CDC currently recommends that people who are immunocompromised and who received the Johnson & Johnson vaccine as their primary vaccine get a second vaccine dose at least four weeks after their first shot to complete their primary series. A J&J vaccine can be given as the second shot but a dose of Pfizer or Moderna is preferred. Again, this will be considered part of the primary series and is covered free of charge.
Additional doses in the primary series are not recommended for the Novavax vaccine at this time.
The first booster shots were in July 2022. The CDC recommended booster shots using Pfizer and Moderna vaccines, regardless of the type of vaccine you received for the primary series. At that time, a booster shot was recommended five months after a Pfizer or Moderna primary series and two months after a J&J primary series. There were initially no recommendations for booster shots after the Novavax vaccine. People who were immunocompromised only needed to wait three months for their first Pfizer or Moderna boosters regardless of the primary series they got.
The timing of booster shots evolved over time. Recommendations are to now receive a booster shot two months after completing the primary series, including Novavax. In fact, an updated booster shot is now available. This shot provides protection against even more variants of the virus. Anyone who got the original booster can get the updated booster shot two months after their prior booster dose. Only one updated booster dose is recommended at this time.
The number of doses of vaccine you get will vary based on your medical history and the specific vaccines you get. You could be eligible for as many as five covered doses. The following summarizes COVID vaccines for adults 18 years and older, based on what primary series was used.
* Two booster shots may be covered if you had previously received a booster dose before the updated boosters were available. Otherwise, you would receive only one updated booster dose.
As recommendations change, on both federal and state level, it may take time for the computer systems and staff training to catch up, so be patient for a few days after big announcements.
At this time, Medicare beneficiaries can get their COVID vaccines for free. That means you will not pay a deductible, coinsurance, or copay for the vaccine itself, administration of the vaccine, or the visit for the vaccine (as long as the visit was not for other reasons).
Medicare beneficiaries will continue to get COVID vaccines for free after the Public Health Emergency (PHE) ends on May 11, 2023. This is the case whether they are on Original Medicare or a Medicare Advantage plan.
Traditionally, Medicare only covers FDA-approved treatments and not treatments under an emergency use authorization. At this time, only the Pfizer and Moderna vaccines have been granted full approval by the FDA but CMS reports that any COVID-19 vaccination that has an emergency use authorization will continue to be covered.
These vaccines will be covered by Medicare Part B, like influenza and pneumonia shots. As long as your healthcare provider accepts assignment, Part B vaccines will not cost you anything.
Tanya Feke M.D. is a licensed, board-certified family physician. As a practicing primary care physician and an urgent care physician for nearly ten years, she saw first-hand how Medicare impacted her patients. In recent years, her career path has shifted to consultant work with a focus on utilization review and medical necessity compliance. She currently works as a physician advisor at R1 RCM, Inc., where she performs case reviews for hospitals nationwide.
Dr. Feke is an expert in the field, having Medicare experience on the frontlines with both patients and hospital systems. To educate the public about ongoing issues with the program, she authoredMedicare Essentials: A Physician Insider Reveals the Fine Print. She has been frequently referenced as a Medicare expert in the media and is a contributor to multiple online publications. As founder of Diagnosis Life, LLC, she also posts regular content about health and wellness to her site at diagnosislife.com.
The end of the public health emergency on May 11, 2023, will result in changes to Medicare's coverage of COVID-related healthcare services, COVID tests and vaccines and telehealth services.
During the pandemic, many of the Medicare enrollees who utilized telehealth did it just by picking up the phone. Here's why audio-only telehealth could be a better option going forward.
The Affordable Care Act legislation included several ounces of prevention for Medicare beneficiaries: free wellness exams plus a range of tests, from mammograms and colonoscopies to glaucoma screenings. Other preventive benefits include flu shots and smoking cessation counseling.
The end of the public health emergency on May 11, 2023, will result in changes to Medicare's coverage of COVID-related healthcare services, COVID tests and vaccines and telehealth services.
During the pandemic, many of the Medicare enrollees who utilized telehealth did it just by picking up the phone. Here's why audio-only telehealth could be a better option going forward.
The Affordable Care Act legislation included several ounces of prevention for Medicare beneficiaries: free wellness exams plus a range of tests, from mammograms and colonoscopies to glaucoma screenings. Other preventive benefits include flu shots and smoking cessation counseling.
