I have Medicare drug insurance. Why did I get this $2,055 bill?!

After Michael Foxhoven learned that Medicare covers shingles and Tdap vaccinations, he made appointments for both himself and his wife at their doctor’s office. Since they were due for a Covid booster, they figured they could also get that out of the way in the same visit.

But a few months after that appointment, Foxhoven got the sticker shock of his life. That’s when he received a $2,055 bill for the vaccinations that he thought Medicare would cover.

So why didn’t it?

The answer will probably surprise you. 

This family’s story is a cautionary example of how making simple assumptions about your Medicare coverage can lead to expensive mistakes.

What is a Medicare Summary Notice (MSN)?

Every quarter, Medicare sends beneficiaries a Medicare Summary Notice (MSN). This document lists all of the treatment and provider claims submitted to Medicare for that person in the prior quarter.

You can find a detailed explanation of how to understand the MSN on the Medicare website. Beneficiaries can get notices more frequently by setting a MyMedicare account and choosing to receive digital notices (email). Medicare Advantage and prescription drug plans have a similar form called an Explanation of Benefits.

This is a screen shot from a portion of the first page of my recent MSN.

Don’t overlook an MSN

It’s critical for beneficiaries to carefully review each Medicare Notification Summary which includes:

• An explanation of treatments and services received,
• whether Medicare approved the treatment
• what the provider charged, what Medicare paid
• What you might owe.
• How much of the charge was sent to a Medicare supplement plan, if any.

In Foxhoven’s case, the notice he got after the first set of shots would have shown that Medicare did not approve the services.  It would have also shown an amount that he could be billed. That should have gotten his attention. His wife would have gotten a similar notice.

If your Medicare Summary Notice says a service was not approved, don’t ignore it and assume Medicare made a mistake. The notice will have a footnote providing an explanation as to why it was not approved. Then, depending on the reason, get more information by calling 1-800-MEDICARE (1-800-633-4227) or talk to a SHIP counselor (I’ll explain that in a moment).

When Foxhoven received his MSN, he assumed Medicare had made a mistake.

“I was not overly concerned at this juncture because the shingles and Tdap vaccinations had only recently been added to Medicare’s list of covered vaccinations,” he explained. “On September 8th, we returned to get the second shingles vaccination.”

As he was soon to learn from another MSN, Medicare would not approve the second shots either.

Medicare subscribers beware: Where you receive your treatment matters

So why didn’t Medicare approve payment for those covered vaccines?

Medicare’s rules for prescription drug coverage can be confusing. The program divides covered medications into three categories: Part A drugs, Part B drugs, and Part D drugs.

Where and how the medication/ vaccines are administered dictates which category the treatement falls.

• Part A drugs are those that are administered during in-patient treatment as part of a covered stay in a hospital or nursing home or for symptom and pain relief in hospice care.
• Part B covers drugs that generally are not self-administered and can be given in a doctor’s office. If an injection usually is self-administered or isn’t given as part of a doctor’s service, Part B generally won’t cover it. However, there are exceptions. Many vaccines are covered, but, as Michael Foxhoven learned later, the shingles and Tdap vaccines are not covered under Part B. They’re covered under Part D
• Generally speaking, Part D covers prescription medications that are FDA and Medicare approved and sold in the U.S. Part D does not cover drugs that would be covered for an individual under Parts A or B.

Where do vaccines fit in?

Which part of Medicare covers a vaccine depends on circumstances.

Medicare Part B covers vaccines for flu, pneumonia, hepatitis B (for individuals at high and intermediate risk), covid-19, and for certain vaccines when they’re used to treat an injury or exposure to a disease. Here’s how the Centers for Medicare and Medicaid Services (CMS) explains tetanus shots:

For example, if a patient gets a tetanus vaccination because of an accidental puncture wound, it’s a Part B-covered vaccine. However, if the patient gets a tetanus booster shot, unrelated to injury or illness, it’s a Part D-covered vaccine.

Centers for Medicare and Medicaid Services

However, most vaccines, including shingles and Tdap, are covered under Part D and that’s where Michael Foxhoven made his mistake.

According to the Medicare website:

Neither Medicare Part A (Hospital Insurance) nor Medicare Part B (Medical Insurance) cover the shingles shot.

Medicare official site

Medicare prescription drug plans (Part D) usually cover all commercially available vaccines needed to prevent illness, like the shingles shot.

For Tdap shots, Medicare’s wording is the same. The vaccinations are covered under Part D but not under A or B. So…

Medicare fact: If a pharmacy administers your vaccinations, you are covered. If you get the same injections in a hospital or at a doctor’s office Medicare will not pay the tab.

Medicare Advantage plans may have different rules regarding where one gets vaccines. Check with your plan to be sure you understand its rules.

How to know if your medications are covered

There are many drugs that are not covered by Medicare, such as for weight loss, hair growth, or symptomatic relief of cough or colds, to name just a few. It’s important to understand that just because a doctor prescribes or administers a medication does not mean your drug plan will cover it.

The best way to know for sure whether a medication or a service is covered by Medicare is to do a search on the Medicare website. The site also has a search box where you can enter a specific drug or procedure.

Another Medicare coverage denial and a past-due notice

After the second round of shingles vaccinations, Foxhoven and his wife received another set of MSNs with the denied coverage alert. He continued to assume Medicare made a mistake.

“It was my intention to wait until I received an actual bill from the doctor,” Foxhoven explained. “I hoped that the claims had been miscoded or the procedures had been billed to Medicare improperly.”

The actual bill for all the shots, totaling $2,055, came in December along with a past due notice.

Foxhoven was frustrated and angry. He knew that the vaccines were supposed to be covered by Medicare. Continuing to believe that the billing department at their doctor’s office had mishandled the insurance claim, he asked for the invoice to be sent to the couple’s drug plans.

That’s when a billing representative told him that wouldn’t be possible.

Since we are a primary care provider, we are not able to bill a patient’s Medicare Part D plan, only pharmacies can do so.

Billing department of the couple’s doctor’s office

And that’s when he reached out to Consumer Rescue to find out what to do next about his inflated Medicare bill.

Who is responsible for this coverage misunderstanding?

Foxhoven is frustrated that no one informed him ahead of time – either  when he made the appointments or prior to administering the injections – that the shots would not be covered by Medicare if he got them at the doctor’s office.

That’s an understandable expectation. But is it realistic?

Medicare coverage rules are complicated. Beyond the vaccine examples I mentioned above, there are procedures that might be covered under one set of treatment or diagnostic circumstances but not under another. There are some diagnostic tests that generally are not covered but may be covered in specific situations.

Doctors, nurses and other medical professionals on their team are seeing patients not only on Medicare but also with various workplace and private insurance plans. They can’t be expected to know all the details of which plan covers what for every patient.

Personal responsibility

It’s likely that the person who booked appointments or the medical professional who administered the injections did not know the details of Medicare’s coverage rules. The billing office should know, but that’s not what this case is about.

It’s different if a patient asks for a procedure that the provider knows is not covered by Medicare. Then the provider has an obligation to tell the patient. As I pointed out previously, there are many things that Medicare does not cover, such as elective procedures or treatments that are considered experimental. If the patient wants those, they will have to sign a form stating that they understand and agree to pay.

In Foxhoven’s case, since Medicare does cover shingles and Tdap vaccines, he may be able to get his prescription drug plan to reimburse some portion and possibly all of what he had to pay the doctor for the shots. He will have to contact the plan directly and then follow its claims process.

How to protect yourself against a surprise, sky-high Medicare bill

Don’t make assumptions. If your doctor or other provider suggests a particular treatment or test, it’s OK to ask them if they know whether Medicare covers it. But to be on the safe side, use the search function on the official Medicare website to find out if it’s covered. If you’re unsure whether a prescription medication is covered, contact your drug plan.

It’s your health and your money. Be an informed consumer.

Here’s a great source of Medicare information: SHIP

You can get free, knowledgeable, and unbiased answers to your Medicare questions from the federally-funded State Health Insurance Assistance Program which is known by the name SHIP.

SHIP is national in scope with branches in every state. The SHIP website has a link to find the program where you live. You can talk to a trained and registered SHIP counselor in person in many cities and by phone in every state. And you can be assured they will not try to sell you insurance.

Disclosure: I’ve been a volunteer SHIP counselor for more than seven years. During that time, my most frequently asked questions involve how to enroll in Medicare and how it works. So watch for an upcoming 101 article that explains the basics of the program. (Abe Wischnia, Consumer Rescue)