Learning Center > A Guide To Medicare Vaccine Coverage

A Guide To Medicare Vaccine Coverage

As we age, we grow more vulnerable to chronic and seasonal illnesses. And many times these illnesses can hit hard and fast, sometimes making it difficult to recover. But taking preventative measures against illnesses, like getting vaccines, is a safe course of action.

To help accomplish this, Medicare beneficiaries have access to comprehensive benefits for routine vaccinations. In this guide to Medicare vaccine coverage, we’ll review how vaccines are covered by Original Medicare and the various private Medicare insurance plans on the market.

The Importance Of Vaccines For Adults Over 65

It’s much easier to avoid getting sick with some illnesses than it is to treat, recover or survive them. This is especially true for those ages 65 and up: Illnesses such as the flu, pneumonia, and COVID-19 can take a heavy toll on this population.

And since most of these illnesses are seasonal by nature, they’re perfect candidates for vaccines. In fact, the CDC recommends that adults ages 65 and over have annual vaccination against the flu.

Studies have shown that seniors who are vaccinated are more likely to avoid seasonal illnesses and have fewer severe symptoms, including a decreased chance of:

  • Doctor’s visits
  • Hospitalizations
  • Death

However, there are non-seasonal vaccinations for adults over age 65. These may include:

  • Varicella / Shingles
  • Tdap
  • Pneumococcal
  • Hepatitis A and B

Quick Medicare Tip: Be sure to check with your doctor for advice on which vaccines to get and how frequently you should receive them. This is especially important because of the potential for interactions with existing health conditions.

What Vaccines Does Medicare Cover?

Medicare vaccination coverage depends on how the specific vaccines are categorized. In other words, vaccines can be covered by Medicare Part B. But in other cases, vaccines are covered by Medicare Part D drug plans.

Medicare Part B Vaccine Coverage

Medicare Part B covers outpatient medical care, broken down into two groups of services:

  • Medically necessary services, and
  • Preventative services

You’ll use Part B for routine healthcare like doctor’s visits and lab work. Unlike Part A of Original Medicare, you’ll probably have to pay a monthly premium to have Part B coverage.

Medicare Part B covers vaccinations under the preventive services category. And many recommended elderly immunizations are included in Medicare Part B vaccine coverage. The following vaccines are among the most important.

Flu Vaccines

Medicare Part B covers influenza vaccinations. Medicare will cover one flu shot per person, per flu season. And you will pay nothing as long as you receive your flu shot from a doctor or other qualified health care worker who accepts Medicare “assignment.” This means that they agree to accept Medicare’s payment as payment in full.

Most doctors and health care practitioners take Medicare Assignment.

Hepatitis B Shots

Medicare Part B vaccine coverage for the Hepatitis B vaccine is a little more complicated. Part B will cover it, but only if you’re at moderate or high risk.

You’re considered to have medium or high risk if any of these apply to you:

  • You have hemophilia
  • You have End Stage Renal Disease (ESRD)
  • You have diabetes
  • You live with someone who has Hepatitis B
  • You’re a healthcare worker and frequently exposed to bodily fluids

If you meet these criteria and receive the shot from a practitioner who accepts Medicare assignment, you’ll pay nothing. The Hepatitis B vaccine may be given as a series of two or three injections, depending on which vaccine is used.

Pneumococcal Shots

Medicare Part B will cover a total of two pneumococcal shots for seniors.

You can get the first shot at any time, and Part B will cover the second shot as long as you receive it at least one year after your first injection. Like other instances of Medicare vaccine coverage, you’ll pay nothing out of pocket if you get the pneumococcal shots from a qualified practitioner who takes Medicare assignment.

COVID-19 Vaccine

As the newest and most urgently needed vaccine on the block, Medicare Part B will cover the COVID-19 vaccine. We’ll review some of the specifics of COVID-19 Medicare Part B vaccination coverage shortly. For now, COVID-19 vaccine coverage through Medicare Part B is all available for no out-of-pocket cost.

Quick Medicare Tip: Need more help understanding Medicare Part B? Visit our Guide to Medicare Part B to learn how Medicare Part B coverage works.

Medicare Part D Vaccine Coverage

Medicare Part D is the prescription drug program for Medicare beneficiaries. Drug coverage is not available as part of the Original Medicare Fee-for-Service program. Instead, it’s offered by private insurance companies.

Medicare Part D drug coverage is available as 2 types of plans:

  • Standalone Prescription Drug Plans (PDP), and
  • Medicare Advantage Prescription Drug (MAPD) Plans.

Whether you get prescription drug coverage from a standalone plan or a Medicare Advantage plan, the drug coverage works the same. In both cases, your insurance company helps pay part of the cost of your medications. Unlike Medicare Part B vaccine coverage, you’ll generally have to pay some share of the cost for Medicare Part D vaccination coverage.

The formal list of drugs and vaccines covered is known as a Medicare Part D formulary. The formulary is an exclusive list. Two things to know:

  • If a drug or vaccine isn’t on the formulary, then the plan doesn’t cover it.
  • If you receive medications of vaccines that aren’t on your plan’s formulary, then the plan won’t cover it and you’ll pay full price.

That said, it’s important to make sure that you only use medications or vaccines that are on your plan’s formulary.

With Part D drug coverage, you’ll usually pay a copayment or coinsurance amount for each drug or vaccination you receive. But this amount can change during the course of the calendar year as you move through the four coverage stages of Medicare Part D. Part D drug plans cover vaccines that are not covered by Medicare Part B. Generally speaking, these vaccines are considered to be less necessary than the vaccines covered by Part B.

And since Medicare Part D vaccine coverage is provided by a private insurance plan, you don’t have to worry about whether your practitioner accepts Medicare assignment. As long as they accept your Part D plan, you’ll only pay the required copayment or coinsurance.

Zoster (Shingles) Vaccine

The shingles vaccine is covered by Medicare Part D plans. The CDC recommends that people over age 65 receive two doses of this vaccine.

MMR Vaccine

Private Part D drug plans cover the Measles, Mumps, and Rubella vaccine in one or two doses if you were born after 1957.

Tdap Vaccine

The tetanus, diphtheria, and pertussis vaccine is eligible to be covered by Medicare Part D plans. The CDC recommends that you receive a new shot every ten years. A more frequent dose may be required in response to some wound care situations.

Again, your vaccine costs will vary based on your individual plan formulary as part of Medicare Part D vaccine coverage. To find out how much you’ll pay, you’ll need to contact your Part D plan.

If you have trouble affording medications including Part D covered vaccinations, you may be able to get assistance through the Extra Help program.

Extra Help is available to people who meet certain income and asset requirements. If you qualify, you’ll pay less for your medications, and you may even get help paying for your Medicare Part D premium. You will have to recertify for Extra Help each year, but the savings are worth the effort.

Quick Medicare Tip: Visit our Guide to Medicare Part D to read more about how Part D coverage works.

How Does Medicare Cover The Coronavirus Vaccine?

As we covered earlier, adults ages 65 and up are more vulnerable to coronavirus than other age demographics. And COVID-19 has definitely taken its toll on this age group.

That’s why it’s especially key that Medicare beneficiaries take advantage of their Medicare benefits, including Medicare coverage for COVID-19. Under a provision of the 2020 CARES Act, any FDA-approved coronavirus vaccine will be covered by Medicare Part B. This includes both two-shot vaccines and single dose COVID-19 vaccines.

As long as the coronavirus vaccines are FDA-approved, Medicare will cover the costs.

Also, since Medicare Advantage is required to have the same coverage as Original Medicare, Medicare Advantage plans also cover the coronavirus vaccine.

Other key things to know about Medicare coverage for coronavirus includes:

  • Medicare covers COVID-19 testing.
  • Medicare covers COVID-19 antibody tests.
  • Medicare covers all medically necessary hospitalizations, including hospital stays for COVID-19 treatment and quarantine requirements.
  • Medicare Advantage plans can’t charge deductibles, copayments and coinsurance for tests that detect or diagnose COVID-19.
  • Medicare Advantage plans may offer additional benefits like telemedicine to keep you out of the waiting room and get non-emergency care at home.

How Does Medicare Cover Travel Vaccinations?

As a general rule, Medicare does not cover vaccinations for international travel. However, some Part D drug plans may offer coverage for vaccinations necessary for travelling outside the U.S. Be sure to contact your Medicare Part D plan to see if this is the case. Otherwise, you’ll need to pay out of pocket for your travel immunizations.

Conclusion: Medicare and Vaccines

Vaccines aren’t just for kids - they’re an important way for all ages to keep healthy and prevent illnesses.

And Medicare vaccine coverage gives those ages 65 and up the support needed to get access to crucial vaccines. After all, preventing infection is much easier than treating certain illnesses, especially those that affect the respiratory system like COVID-19, flu, and pneumonia.

Through Medicare Part B of Original Medicare and Medicare Part D drug plans, you can be sure that necessary vaccines will be covered at the optimal doses and frequency.

But just because a vaccine is recommended for most people and covered by Medicare doesn’t mean that you should run out and get it. Some vaccines may not be suited to you based on your individual health status and history. For this reason, it’s critical that you speak with your doctor about the vaccines you should and shouldn’t receive.

You can also learn more about Medicare coverage for vaccines on the benefits provided by your Medicare insurance plan. Just remember: Part D plans change their formularies every year, so the costs of Medicare Part D vaccines may change. Always review your coverage during the Medicare Open Enrollment Period, and consider switching to a plan that better suits your needs if necessary.

If you’d like to get help finding a Medicare plan, call 800-620-4519 to speak with one of our licensed insurance agents, or click to try our Medicare plan comparison tool to find Medicare Advantage or Prescription Drug Plans near you.


The above information does not constitute medical advice. Always consult with a medical professional regarding your health needs. If you are experiencing a health emergency, contact your local emergency health services immediately or visit the nearest emergency room or urgent care.

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If you’re enrolled in Part A and B before age 65 due to a disability or chronic condition, you’re still eligible for Medicare Advantage coverage. How Do Medicare Advantage Plans Work? Medicare Advantage health care plans work like the employer-sponsored health insurance plans you may be used to from your previous or current job. Medicare Advantage plans provide comprehensive coverage, and you usually need to stay in-network to receive care. You’ll typically have some out-of-pocket expenses when you receive services and procedures under your Medicare Advantage policy. These costs typically come in the form of copayments or coinsurance that you’ll pay to your provider when you receive care. An important point to remember is that all Medicare Advantage plans have an annual out-of-pocket (OOP) maximum that limits the total amount you can spend in any year. But you do not have an OOP with Original Medicare. What Types Of Medicare Advantage Plans Are Available? 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Who Is Medicare Advantage Good For? You should consider enrolling in Medicare Advantage if: You want to put a cap on your total out-of-pocket spending under Original Medicare. You want prescription drug coverage without paying for a separate Part D drug plan. You need some of the extra benefits (vision, hearing, private home aides) that come with many Medicare Part C plans. You don’t want to pay for Medicare Supplement (Medigap) plans. You don’t mind using a network of doctors and facilities. You don’t mind needing referrals to see specialists. You don’t mind paying small copays each time you see a doctor. How Much Does Medicare Advantage Cost? Medicare Advantage plans have several costs associated with them. Before we dive into each cost, it’s important to remember that you always have to pay your Part B premium in order to have Medicare Advantage. Now, some Medicare Advantage plans offer a benefit that covers part, or all, of your Part B premium. But check the plan benefits closely to see if this is offered by a specific Medicare Advantage plan. Beyond this Part B premium, you might face the following Medicare Advantage plan costs: Monthly premium Annual deductible Copayment Coinsurance You might have a monthly premium for your Medicare Advantage plan, but these premiums tend to be low. For example, the average Medicare Advantage premium was $23.63 per month in 2020. However, many Medicare Advantage plans do not have a monthly premium. In 2020, 60% of people enrolled in Medicare Advantage didn’t pay a monthly premium. Some Medicare Part C plans have an annual deductible, but again, many do not. If your plan does have an annual deductible, this means you’ll have to pay a certain amount before the plan begins paying benefits. Note that there may be separate deductibles for drug coverage and medical benefits. 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Change from one prescription drug plan (Medicare Part D) to another. Enroll in a prescription drug plan. Cancel your prescription drug coverage. If you enroll in, or switch your Medicare Advantage insurance during AEP, your new coverage will be effective on January 1st of the following year. You may also be able to enroll in a Medicare Supplement plan if you drop your Medicare Advantage coverage during AEP. The Medicare Advantage Open Enrollment Period If you’re enrolled in a Medicare Advantage plan, you have access to another enrollment period beyond AEP: The Medicare Advantage Open Enrollment Period (MA-OEP). MA-OEP runs from January 1 to March 31 of each year. During the MA-OEP, you can: Change from one Medicare Advantage plan to another. Drop Medicare Advantage, and return to Original Medicare. Add a Prescription Drug Plan if you return to Original Medicare. It’s important to keep in mind that the MA-OEP is only for people who already have a Medicare Advantage plan. If you change plans during the MA-OEP, your new coverage will be effective on the first day of the month after you enroll. Medicare Advantage & ESRD Coverage For all years before 2021, there was an exclusion for people with permanent kidney failure, known as End-Stage Renal Disease (ESRD). ESRD patients could not get new Medicare Advantage coverage. However, beginning January 1, 2021, ESRD patients will be able to enroll in or switch Medicare Advantage plans. Now the eligibility for Medicare Advantage and Original Medicare will be perfectly aligned. Medicare Advantage And Other Special Scenarios We mentioned earlier that Special Needs Plans (SNPs) are a type of Medicare Advantage insurance. Let’s take a look at some common types of SNPs, and how Medicare Advantage health plans are also helping people to get access to care and benefits during the coronavirus pandemic. Medicare Advantage And Chronic Conditions There are Medicare Advantage plan options for people with chronic conditions like diabetes and heart disease. These plans are known as Chronic Special Needs Plans (Medicare C-SNPs), and the benefits are tailored to help you treat and manage your chronic condition. These health plans often provide you with a care coordinator to make sure your needs are being met. These Special Needs Plans have Special Enrollment Periods (often called SEPs), so if you qualify for a C-SNP, you can enroll in it at any time. You won’t have to wait for an annual enrollment window. Medicare Advantage And Medicaid Another kind of Special Needs Plan exists for “Dual Eligibles” – people who are eligible for both Medicare and Medicaid. These plans, called Dual Eligible Special Needs Plans (D-SNPs), have cost-sharing that conforms to the Medicaid program, which means that most costs are $0. D-SNPs incorporate various prescription drug discount programs, depending on your income level - so you’ll save money on your prescriptions if you qualify. D-SNP plans also have more favorable enrollment windows, which allow you to access the benefits once you become eligible for Medicaid or extra help and at certain times during the year without waiting for an annual enrollment window. Medicare Advantage And COVID-19 Medicare provides Coronavirus coverage to help people combat the virus, which includes: No-cost lab testing. Antibody testing. All medically-necessary services and procedures, including hospitalizations and doctor’s visits. Coronavirus vaccine coverage, when one becomes available. Many Medicare Advantage health plans are waiving cost-sharing for these services. In this case, you wouldn’t pay a copayment or coinsurance for seeing a doctor or going to the hospital if you have COVID-19. Medicare has also approved an expanded role for telehealth and virtual doctor’s visits. And many Medicare Advantage health care plans offer these no-contact services with no out-of-pocket cost to you. Medicare Advantage Plan Ratings Every established Medicare Advantage plan is given a Medicare Start Rating by the Centers for Medicare & Medicaid Services (CMS). Star ratings range from 1 to 5, with 5 stars being the highest. Here’s a breakdown of what each rating means: 5-star rating: Excellent 4-star rating: Above Average 3-star rating: Average 2-star rating: Below Average 1-star rating: Poor Medicare Advantage plans are rated on several different metrics and are given an overall rating. This Medicare star ratings system is designed to help you get a feel for the level of quality and satisfaction a MA plan offers. Star ratings also give you an idea of how well a plan treats its members. Plans are rated on how quickly it responds to appeals and complaints and how they cover health screenings and preventative services. Plans are also rated for both medical benefits and prescription drug benefits, if the plan has drug coverage. How To Enroll In A Medicare Advantage Plan If you want to enroll in a Medicare Advantage plan, you’ll want to consider 3 things before joining: Make sure you find a plan that’s available in your area. Most Medicare Advantage plans are restricted to specific counties or states. Make sure your current doctors and medications are covered. This is especially important if you’re looking at a Medicare Advantage HMO plan. You’ll have to use the doctors that are in-network, and you’ll only get coverage for medications that are on the plan formulary. So make sure you investigate these before enrolling. Pay attention to star ratings. This can help you compare the overall quality among different plans. But keep in mind that new plans are not given star ratings until enough data has been collected for CMS to calculate a rating. Once you’ve found a plan, you have a few options to enroll, including: Online, by phone, or paper enrollment directly with the insurance company. Working with a licensed health insurance agent who can help you find, compare, and enroll in a Medicare Advantage plan of your choice. Medicare Advantage Guide Conclusion Medicare Advantage plans can be a great way to manage your out-of-pocket spending while enjoying extra benefits we covered, if you qualify. And they can offer some compelling advantages over Original Medicare, depending on your healthcare needs. So if you'd like to learn more about Medicare Advantage plans in your area, call 800-620-4519 to reach a licensed insurance agent who may be able to guide you to the right plan for your needs. You can also try online Medicare plan comparison tool.
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The transition from 2020 to 2021 offers many opportunities for people on Medicare. Whether you use Original Medicare, Medicare Advantage, or Medicare Supplement Insurance, you’ll find plenty of changes on the horizon. In this guide to 2021 changes to Medicare, we’ll review what happened during 2020, and dive into the Medicare changes and opportunities for 2021. Review of 2020 Medicare Changes To say that a lot happened in 2020 is a cosmic understatement. The big disruptor, of course, was COVID-19. The pandemic led to some sizable changes in the Medicare program. Some of the highlights from 2020 include: Medicare Supplement (Medigap) Plans C, F, and High Deductible F (HDF) were no longer available to newly-eligible beneficiaries as of 1/1/2020. For the second year in a row, the infamous “Donut Hole” was closed for Part D drug plans. Medicare expanded access to telehealth/virtual doctor appointment services. Many insurance companies, including the major Medicare Advantage plan sponsors, reduced or waived copayments for COVID-19-related care. Other than the COVID-19-related changes, the loss of Medigap Plans C, F, and HDF was probably the biggest change to Medicare for 2020. Those plans became unavailable for beneficiaries who first became eligible after 12/31/2019. This leaves Plan G as the most comprehensive Medigap plan available to all new Medicare beneficiaries. This plan will cover 100% of your Medicare deductibles, copayments, and coinsurance except for the Part B deductible. You’re responsible for the first $198 in Part B expenses for 2020. 2021 Medicare Costs 2021 Medicare Part A Costs Most people don’t pay a Part A premium because they paid Medicare taxes while working. So if you don’t get premium-free Part A, you pay up to $471 each month. Hospital Stays In 2021, you pay: $1,484 deductible per benefit period. $0 for the first 60 days of each benefit period. $371 per day for days 61–90 of each benefit period. $742 per “lifetime reserve day” after day 90 of each benefit period (up to a maximum of 60 days over your lifetime). Skilled Nursing Facility Stays In 2021, you pay: $0 for the first 20 days of each benefit period. $185.50 per day for days 21–100 of each benefit period. All costs for each day after day 100 of the benefit period. Medicare Part B Costs Most people will pay the Part B premium of $148.50 for 2021, but Social Security can share your exact Part B premium amount. You can also refer to the 2021 Medicare Costs guide from Medicare.gov for a complete breakdown of Medicare Part B premiums. Medicare Advantage Plan Changes For 2021 Many of the most exciting and notable 2021 changes to Medicare encompass Medicare Advantage plans. These plans, which are also known as Part C plans, are a private insurance alternative to Original Medicare. Medicare Advantage And ESRD The single biggest piece of news about Medicare Advantage for 2021 relates to those with End Stage Renal Disease (ESRD), also known as kidney failure. Beginning 1/1/21, Medicare beneficiaries with ESRD will be able to get coverage through Medicare Advantage plans. Prior to 2021, Medicare Advantage plans were generally able to exclude people with ESRD. This left ESRD patients in a tough spot, since under Original Medicare Part B, they paid 20% of the cost of dialysis. And this can get expensive very quickly since there was no out-of-pocket cap on their expenses under Original Medicare. Everyone with ESRD will now be able to get Medicare Advantage coverage. This may not reduce the amounts ESRD patients pay early in the year, since many Medicare Advantage plans charge a 20% coinsurance for dialysis as well. However, the great news for ESRD patients is that every Medicare Advantage plan has an annual out-of-pocket maximum. So once ESRD patients hit their annual spending caps, they’re not required to pay for any more medical expenses the rest of the year. Medicare Advantage And Hospice Benefits Another 2021 change to Medicare Advantage is a small test program for delivering hospice benefits. Historically, hospice coverage was provided by Original Medicare, even if you were in a Medicare Advantage plan. Starting in 2021, 53 Medicare Advantage plans across the country will provide hospice and palliative care. This is a very small number of plans, so it won’t affect most people at this point. However, if the test program works, you may see more Medicare Advantage plans offering this benefit in the future. Extra Benefits Through Medicare Advantage Plans Medicare Advantage is the subject of other big 2021 changes to Medicare. Beginning in 2021, additional benefits will be available. Extra benefits are benefits offered by Medicare Advantage plans that are not covered by Original Medicare. Examples may include: Dental coverage Vision and hearing coverage Chiropractic care For 2021, new Medicare benefits will be available. Many of them are designed to help you get care at home, and lend some support to caregivers. The new extra Medicare benefits in 2021 available through some Medicare Advantage plans include: Caregiver support Adult day health services In-home support services Therapeutic massage Acupuncture (for chronic low back pain only – this is also now covered under Original Medicare) But these extra benefits are not required or guaranteed. Instead, they are optionally provided by Medicare Advantage plans, and they can be changed or discontinued from year to year. Still, the availability of adult day health services and caregiver support will be beneficial for many of those on Medicare who struggle to care for themselves. For 2021, Medicare Advantage plan premiums are lower on average than in the past. In fact, the average Medicare Advantage plan premium is expected to be 11% lower in 2021 than in 2020. For 2021, the average Medicare Advantage plan premium will be $21 per month. On the other hand, the annual out-of-pocket maximum for in-network services is rising to $7,550. This is the highest it can be. Many plans will continue to offer lower out-of-pocket maximums. 2021 Changes To Medicare Drug Plans The other big news in 2021 changes to Medicare is the Part D Senior Savings Model. This model program, which is essentially a five-year test, will cap the price of a 30-day supply of many insulins at $35. Under this new program for 2021, beneficiaries will have access to about 1,700 MAPDs (Medicare Advantage plans with Part D drug benefits) and stand alone Prescription Drug Plans that cap the cost of insulin. Another great detail about this program is that the cost for insulin won’t change, even if you enter the coverage gap during the year. You’ll still pay the same capped copayment. In addition, you won’t have to meet a deductible to get the $35 copay price. While not every plan has chosen to participate, CMS expects there to be at least one plan in all 50 states, the District of Columbia, and Puerto Rico. Given the effect of diabetes on the kidneys, patients with ESRD are in position to grab some great new benefits for 2021 and beyond. How To Prepare For 2021 Changes To Medicare For starters, you should make note that we expect a slight increase in Original Medicare costs, for 2021. Though we still don’t know what they’ll be, we expect there to be some increase in the Part B premium, even with the caps that will limit the total rise in costs. You can expect the same thing with deductibles. As with a normal Medicare Open Enrollment Period, also called the Medicare Annual Election Period (AEP), you should review your current coverage to see if switching plans for 2021 makes sense. New plans are available each year, so Medicare beneficiaries have until December 7 of each year to make a change to their plans for the following year. When comparing plans during the Medicare Open Enrollment Period, be sure to look at: The monthly premium (if any) Annual deductibles (if any) Cost structure, like copays and coinsurance amounts for Medicare Advantage and Prescription Drug Plans Out-of-pocket maximum amounts for Medicare Advantage plans Networks of doctors and medical facilities for Medicare Advantage plans Tip: It’s important to not just jump into a new plan because it has one appealing feature. You want to make sure that your doctors accept any new plan and that your current medications will be covered. If you use insulin, you may want to consider one of the standalone Prescription Drug Plans or MAPD plans participating in the Senior Savings Model program, if available. It’s estimated that those on insulin could save more than $400 per year on average. Besides savings on insulin through the Senior Savings Model program, ESRD patients who don’t currently have Medicare Advantage plan coverage should consider it for 2021. Moving to Medicare Advantage could help ESRD patients in 2 different ways: Moving from Original Medicare to Medicare Advantage Moving from Medicare Supplement Insurance to Medicare Advantage In the first case, you can take advantage of the out-of-pocket spending cap that a Medicare Advantage plan can offer. The out-of-pocket cap could be a real benefit for ESRD patients since it’s not only dialysis treatments that could count against the Medicare out-of-pocket maximum (OOPM). All spending on Medicare-approved services and procedures count towards the OOPM, so an ESRD patient might “max out” their spending during 2021 and get substantial relief the rest of the year. On the other hand, if you have ESRD and are currently covered by a Medigap (Medicare Supplement) plan, you might be able to save money on your monthly premium by switching to Medicare Advantage. And you might save money or come close to breaking even by switching from Medigap to Medicare Advantage, depending on the premiums and out-of-pocket maximums for plans in your area. Just be sure you run the numbers before making this move. Note: It can be difficult to get Medicare Supplement insurance coverage back after you move away from it. You might have to go through medical underwriting, which means you may be declined coverage as an ESRD patient with a pre-existing condition, unless you qualify for a guaranteed issue period. Due to the complexities of Medigap coverage, it’s a great idea to talk to a licensed insurance agent to see if switching to Medicare Advantage is a good idea. Get Help With Medicare If you still have questions about 2021 changes to Medicare and how they impact you, call 800-620-4519 to get help from one of our licensed insurance agents. Or you can try our free Medicare plan comparison tool to find Medicare plans in your area. There is no obligation to enroll in a plan.
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