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, we explain when Medicare covers all costs relating to the pneumonia shot and when it covers only part of them. Then, we discuss pneumonia and its symptoms.
Lastly, we look at the types of pneumonia shots available, who should get them, who should not get them, and the possible side effects.
We may use a few terms in this piece that can be helpful to understand when selecting the best insurance plan:
- Deductible: This is an annual amount that a person must spend out of pocket within a certain time period before an insurer starts to fund their treatments.
- Coinsurance: This is a percentage of a treatment cost that a person will need to self-fund. For Medicare Part B, this comes to 20%.
- Copayment: This is a fixed dollar amount that an insured person pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
Medicare plans offer full or partial coverage for pneumonia shots.
Original Medicare 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. Since Part B covers the pneumonia shots, Part D does not cover them.
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.
Pneumonia is an infection in one or both lungs.
Doctors do not always know which germ caused a person to get sick with pneumonia. Common causes include:
- bacteria, viruses, and fungi
- inhalation of a chemical or liquid
- Streptococcus pneumoniae
- healthcare factors
A person can have community-acquired pneumonia, healthcare-associated pneumonia, or ventilator-associated pneumonia.
Symptoms range from mild to severe. A person should call their doctor if they:
- have shaking chills or a high fever
- have a cough with phlegm that lingers
- experience chest pain when coughing or breathing
- have shortness of breath when engaging in everyday activities
- feel suddenly worse after the flu or a cold
Pneumonia can be a life threatening illness. According to the Centers for Disease Control and Prevention (CDC), the infection resulted in 49,157 deaths in 2017.
Two types of vaccines can help protect people from pneumonia. The first, which is the pneumococcal conjugate vaccine, or PCV13, guards against 13 strains of the bacteria. The second, which is the pneumococcal polysaccharide vaccine, or PPSV23, guards against 23 strains.
When S. pneumoniae produces a severe infection of the lungs, it is called pneumonia. However, the bacteria may also cause a serious infection of the bloodstream — a condition called bacteremia. In addition, it may cause an infection of the lining of the brain and spinal cord, which is known as meningitis.
While both vaccines offer protection from bacteremia and meningitis, only PCV13 gives protection from pneumonia.
PCV13 pneumonia shot
CDC guidelines for who should get the PCV13 vaccine include all children under the age of 2 and all people aged 2 and older with certain medical conditions.
PPSV23 pneumonia shot
CDC guidelines for who should get the PPSV23 vaccine include:
- all adults aged 65 and older
- adults aged 19–64 who smoke cigarettes
- individuals aged 2–64 who have certain medical conditions
For the PPSV23 shot, doctors advise anyone who falls in the above three categories to get a single dose. In addition, the CDC recommend that people with some chronic medical conditions get one or two extra doses.
Even when someone falls into one of the CDC-recommended groups of people who need the shots, they should avoid them under certain conditions.
People who are feeling unwell should not usually get either type of pneumonia shot. Instead, they should wait until they recover. However, if they have a mild cold, it is probably safe to get the shot.
Someone should avoid the PCV13 vaccine if they have had a life threatening allergic reaction to:
- the PCV13 shot
- any component of the PCV13 shot
- an earlier pneumonia shot called PCV7
- a vaccine containing diphtheria toxoid
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.
There is no evidence that PPSV23 may harm a woman who is pregnant or the baby. However, as a precaution, it is best for a woman who needs the shot to get it before becoming pregnant, if possible.
Side effects of the shot are usually mild and disappear within a few days. However, the shot may sometimes cause serious side effects.
Mild side effects
The following mild side effects may occur with the PCV13 shot:
In addition, young children who get the PCV13 shot are at a higher risk of seizures from fever.
Mild side effects of the PPSV23 shot may include:
- redness and pain at the injection site
- muscles aches
Serious side effects
Serious problems after any vaccine, including the pneumonia shot, are seldom, but they do occur. These involve:
- vision changes
- ringing in the ears
- severe shoulder pain
- severe allergic reaction
Any vaccine may cause a severe injury or death, but the likelihood is extremely small.
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.
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