Does Medicaid Cover the Pneumonia Vaccine?

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  • Does Medicaid cover the pneumonia vaccine? This article explains how Medicaid eligibility for the pneumonia vaccine works and how often you should get a shot.

Pneumococcal pneumonia is the most common type of bacterial pneumonia in the United States, and you're 3.8 times more likely to develop the infection if you're aged 65 or over. Fortunately, having a pneumococcal vaccine can reduce the chances of becoming seriously ill with pneumonia, and many health care plans include the vaccine in their coverage. 

Does Medicaid cover the pneumonia vaccine? Below, you can find out who's eligible for a pneumonia vaccine through Medicaid and how often you should get a shot. 

Does Medicaid Cover the Pneumonia Vaccine?

Children and young people under 21 enrolled in Medicaid are covered by the Early and Periodic Screening, Diagnostic and Treatment (EPSDT) benefit. This benefit entitles them to receive any vaccine recommended by the Advisory Committee on Immunization Practice (ACIP), including the pneumonia vaccine. 

Furthermore, the Vaccines for Children (VFC) program provides free vaccines for children aged 18 or younger if they are enrolled in Medicaid, don't have adequate private health care insurance or are an American Indian or Alaska Native. States charge an administration fee for vaccines provided through the VFC scheme, and the fee varies from state to state. However, Medicaid will pay the fee for Medicaid-enrolled children.

Medicaid pays for ACIP-recommended vaccines for adults if they are eligible for all essential health benefits (EHB), including the pneumonia vaccine. Eligible beneficiaries receiving all EHBs are not subject to cost-sharing.

If you're an adult Medicaid enrollee but aren't eligible for EHBs, whether you can get a pneumonia vaccine through Medicaid depends on the rules in your state. Adult vaccines are not a mandatory Medicaid benefit for non-EHB beneficiaries, so states can decide whether to pay for vaccines and which vaccines to fund. Although many states cover certain ACIP-recommended vaccines for all adult enrollees, you'll need to check if yours covers the pneumonia vaccine. You can find out by contacting the state Medicaid Agency

Does Medicare Cover the Pneumonia Vaccine?

Medicare Part B is likely to cover the pneumonia vaccine if your health care provider accepts the assignment. You are not required to make any contributions toward the cost of your vaccines.

If you're eligible, Medicare coverage entitles you to the first shot and then a second shot at least a year later if it is a different vaccine. Having two different pneumonia vaccines can give you more comprehensive protection because it helps you develop immunity against more than one strain. 

Your doctor may recommend getting a pneumonia shot more often than Medicare covers if you have certain health conditions. You are responsible for paying for any additional shots out of pocket. 

Although some providers choose to offer additional benefits, Medicare Advantage Plans must provide the same benefits as Original Medicare. Therefore, you will be entitled to a pneumonia vaccine through your Medicare Advantage Plan if you had been eligible through Original Medicare. 

Are Pneumonia Shots Free for Seniors?

If you are aged 65 or older and enrolled in Medicaid or Medicare, you will most likely be entitled to two free pneumonia shots as long as each shot is a different vaccine. Most private health care insurance plans also cover the pneumonia vaccine, but this may be subject to cost-sharing. You should check with your insurer to determine if you are liable to pay anything towards your pneumonia vaccine. 

How Often Should You Get a Pneumonia Shot After Age 65?

There are two types of pneumococcal vaccine given in the United States: PCV13 and PPSV23. The PCV13 vaccine protects against 13 different pneumonia strains while the PPSV23 protects against 23 strains. Having both vaccines can give you better protection against a wider range of pneumococcal bacteria. 

ACIP recommends that adults aged 65 and over receive the two pneumococcal vaccines in series. If you reach 65 without receiving a dose of the PCV13 vaccine, you can choose whether to have the PCV13 vaccine in consultation with your doctor. If you choose to have it, ACIP recommends waiting for at least a year after your shot and then receiving a dose of the PPSV23 vaccine. You shouldn't receive both vaccines at the same appointment. 

People aged 65 and over do not need a booster dose of either vaccine, but people younger than 65 may require a second dose of the PPSV23 vaccine if they have certain medical conditions. If you choose to receive both the PCV13 and the PPSV23 vaccines, you should have the PCV13 vaccine first.

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