Many readers have questions about health insurance and the Affordable Care Act. Here are some answers.
Q. I have Medicare and a Plan F Medigap plan, so I should be covered for all medical needs. But to get the shingles vaccination, it will cost me $185. I can’t pay this without using my grocery or prescription money. What can I do?
Shingles is a painful rash caused by a virus that can lead to long-term nerve damage. All Medicare Part D prescription drug plans cover the shingles vaccine, which is recommended for people 60 and older. But Medigap plans, which may cover the deductible and coinsurance amounts for services provided under Medicare Parts A and B (hospitalization and outpatient care), don’t offer any financial help on the co-payments for vaccines and other drugs covered under Part D.
A Government Accountability Office report found that seniors faced many obstacles to getting needed vaccines, including the shingles vaccine. Many physicians don’t recommend or even stock the shingles vaccine, the report found. The amount that the patient pays out of pocket for that vaccine could also be a barrier, according to the report.
If the only health coverage you have is through Medicare and your Medigap plan, there are still ways you may be able to reduce your co-payment for the vaccine.
First, if you have Part D coverage, contact your plan to make sure the co-payment you’re being quoted is accurate.
In addition, many doctors who don’t stock the vaccine ask patients to buy it from the pharmacy. If that’s the case, make sure the pharmacy is in your plan’s network so you’ll owe a smaller co-payment than if you buy the vaccine from an out-of-network pharmacy.
If the vaccine co-payment is still too high, it may be worth looking into other Part D plans or signing up for one during the upcoming annual enrollment period, Oct. 15 to Dec. 7. (See Karen Garloch’s column, 1D.) Depending on your other prescription drug needs and coverage, you may be able to find a better deal, Lipschutz says.
It’s worth noting that under the Affordable Care Act, people who have new private health insurance plans and those whose plan benefits have changed significantly are eligible to receive, free of charge, vaccines recommended by the CDC’s Advisory Committee on Immunization Practices. Plan members who are in their early 60s, therefore, might qualify for a shingles vaccine without a co-pay.
Q. Do I have to keep my 18-year-old child on my health insurance?
No. The Affordable Care Act requires insurers to offer to cover adult children of policyholders until age 26, but it doesn’t require parents to purchase that coverage.
Q. What’s to stop a teenager from getting her own individual policy once she finds out she’s pregnant, if her parents’ plan won’t cover her maternity care?
Although health plans must offer to cover adult children on their parents’ plans until they reach age 26, insurers aren’t required to provide them maternity benefits. In that case, a young person or her parents might consider buying an individual policy, as this questioner suggests. But they may run into obstacles.
First, if someone is 19 or older and pregnant when she applies for an individual policy, insurers will likely turn her down because the pregnancy will be considered a pre-existing medical condition.
In the individual market, insurers can and do turn people away if they have medical conditions, even temporary ones like pregnancy. The rationale is to discourage people from waiting until they’re ill or pregnant to buy insurance, say experts.
If the woman is younger than 19, she may have better luck getting coverage. Under the health law, insurers can no longer deny coverage to children younger than 19 because of pre-existing medical conditions. These young people may be eligible for “child-only” individual policies – if their state sells them.
Even if the policies are available, there may be a hitch: The plan may not cover maternity care, and even if it does, the premiums may be pricey.