Are vaccines covered by insurance?

Vaccines are expensive, particularly the newer ones. While most people who have health insurance assume that those injections are covered in full by their policies, that might not be the case for everyone or for all vaccines. Here’s what you need to question before receiving any immunizations if you want to be sure to avoid receiving bills for their administration.

Vaccines are billed by physicians in 2 parts with 2 different procedure codes: the first part is the charge for the vaccine itself; the second charge is for the administration of the vaccine to the patient. These codes are sometimes accompanied by an additional code for an office visit.

In order to be paid by insurance, certain vaccines like those for pneumonia or shingles must be administered according to the age of the patient. Others can be given regardless of age, like the flu vaccine. Additionally, certain vaccines can be given only within or after a specified time frame: for example, the tetanus booster is typically covered every 10 years.

The newer generation of vaccines often have their own qualifications. Prevnar, an add-on vaccine for a specific strain of pneumonia, can be given in addition to the standard pneumovax vaccine, but there must be 12 months separating the administration of each injection in order for most insurances, especially Medicare, to cover the costs.

How much does it cost to get immunizations?

To avoid having to incur the expense of these costly injections, be sure to speak with your health insurance company prior to receiving a vaccine. They will confirm what qualifications are necessary and what costs, if any, might be associated with your receiving the immunizations. It’s better to know in advance what your financial responsibility might be rather than have to deal with medical debt for unexpected and unmanageable expenses after the fact.

Additionally, when an office visit is billed on top of the 2 vaccine codes, you need to pay attention to the coding of that encounter. If you only went to the doctor for the vaccines and for no other medical reason, the doctor should not be billing an office code in addition to the vaccine administration code. If you came in for vaccines and because you had another medical issue, the office visit must be coded to reflect that it is separate and distinct from the vaccine need. If it isn’t, your insurance probably will not pay for it and you may receive a bill for those charges. Even when the office visit code is justified, be aware that most likely, you will be required to pay a copay for the visit. A copay is typically only required for an office visit or for some testing, not for the administration of vaccines.

If you are plagued by health insurance coverage issues like this, or need medical bill assistance, reach out to a qualified patient advocate for help.



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