Original Medicare provides 100% coverage of two pneumonia shots. Medicare Advantage may also cover the total cost of pneumonia shots.
Two types of available vaccines help protect against different strains of a common variety of bacterial pneumonia.
Below, the article explains when Medicare covers all costs relating to the pneumonia shot and when it covers only part of them. Then it looks at the types of pneumonia shots available, who should get them, and who should not get them.
Finally, it discusses pneumonia and its symptoms.
Glossary of Medicare terms
- Out-of-pocket cost: This is the amount a person must pay for care when Medicare does not pay the total amount or offer coverage. Costs can include deductibles, coinsurance, copayments, and premiums.
- Premium: This is the amount of money someone pays each month for Medicare coverage.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before Medicare starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, coinsurance is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare plans offer full or partial coverage for pneumonia shots.
Full coverage
Original Medicare (Parts A and B) covers two pneumonia shots under Part B, which is medical insurance.
Coverage includes the first shot at any time. It also includes the second shot, if a person gets it at least 1 year after the first shot. As long as a person goes to a provider that accepts Medicare, they pay nothing.
Medicare requires Advantage plans to cover the cost of pneumonia shots without applying copayments, coinsurance, or deductibles. The coverage is 100% as long as a person goes to an in-network provider.
Medicare Part D is prescription drug coverage that is available to people with Original Medicare. It includes coverage of medically necessary vaccines that Part B does not cover. However, since Part B covers the pneumonia shots, Part D does not cover them.
Partial coverage
The Original Medicare and Medicare Advantage coverage of the pneumonia shot is free of charge because it falls under Part B preventive services.
However, if a doctor discovers a problem that needs investigation when a person receives the pneumonia shot, the additional testing and care fall under Part B diagnostic services. Copayments, coinsurance, and deductibles apply to these costs.
A Medigap plan, which is Medicare supplement insurance, helps with costs associated with Part B diagnostic services. Some plans pay the Part B deductible, and others pay part or all of the Part B coinsurance and copayments.
Read about Original Medicare vs. Medicare Advantage.
Two types of vaccines can
- pneumococcal polysaccharide vaccine (PPSV23)
- pneumococcal conjugate vaccines (PCVs, typically PCV15, PCV20, and PCV21)
When S. pneumoniae produces a severe infection of the lungs, it is called pneumonia. In addition, it may cause an infection of the lining of the brain and spinal cord, which is known as meningitis.
Pneumonia shots
Learn more about the pneumonia vaccine.
According to the
They also recommend that adults 50 years old and older, or those between the ages of 19 and 49 years old with certain health risks, get vaccinated.
Health risks and chronic conditions that may qualify a person for a pneumonia shot
- weakened immune systems
- cancer
- HIV
- those with their spleens removed
- asthma
- sickle cell disease
- those who smoke
Childhood recommendations
The
Children with health risks or chronic conditions may require more vaccines than those without these conditions. Parents or caregivers should speak with the child’s healthcare professional about pneumococcal vaccines and the types the child may require.
Adult recommendations
For adults who have never received a PCV, the
- those over 50 years old
- those between the ages of 19 and 49 years with health risks or chronic conditions
If a person receives PCV15, then a follow-up dose of PPSV23 is needed.
Adults who received earlier versions of PCV, such as PCV7 or PCV13, should discuss their options with their healthcare professional.
Even when someone falls into one of the CDC-recommended groups of people who need the shots, they should avoid them under certain conditions.
Severe allergies
Someone
- any type of PCV
- any vaccine containing diphtheria toxoid, such as the DTaP vaccine
- any other component of the vaccine
An individual should avoid the PPSV23 vaccine if they have had a life threatening allergic reaction to the PPSV23 shot or any component of the PPSV23 shot. Children under the age of 2 years old should also not receive the PPSV23.
Side effects of the pneumonia shot are usually mild and disappear within a couple of days.
The following mild side effects
- skin discoloration, pain, or swelling at the injection site
- tiredness
- fever
- chills
- loss of appetite
- headache
- muscle aches or joint pain.
Mild side effects of the PPSV23 shot may include:
- skin discoloration and pain at the injection site
- muscles aches
- fever
- tiredness
Rarely, the pneumococcal vaccine
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Original Medicare offers 100% coverage of two pneumonia shots if a person waits 1 year after the first shot before getting the second. An individual must get the shots from a Medicare-approved provider.
Advantage plans offer the same coverage, providing a person gets the shot from an in-network provider.
People who are 50 years old and older have a higher risk of contracting pneumonia. Because of this risk, the CDC recommends that they get the pneumonia shot.