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Medicare SSBCI vs. VBID: What’s the Difference

Two major innovations in the Medicare Advantage (MA) program; special supplemental benefits for the chronically Ill (SSBCI) and the Value-Based Insurance Design (VBID) Model, both aim to improve outcomes for beneficiaries with chronic conditions. However, they differ in purpose, eligibility, benefits, and future outlook. Here’s what you should know about Medicare SSBCI vs VBID and how they compare.

What Is SSBCI

The Special Supplemental Benefits for the Chronically Ill (SSBCI) program was created under the Bipartisan Budget Act of 2018. It allows Medicare Advantage plans to offer non-traditional, non-medical benefits designed to help people with serious chronic illnesses maintain or improve their health and daily function.

To qualify, a beneficiary must:

1. Have one or more complex chronic conditions,
2. Be at high risk of hospitalization or other negative outcomes, and
3. Require intensive care coordination.

Unlike standard Medicare benefits, SSBCI may cover services such as healthy groceries, home air-quality equipment, pest control, transportation, or home modifications. These benefits address social factors that affect health, such as nutrition, housing, and access to care.

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SSBCI benefits are optional, meaning not every MA plan offers them. Plans also decide what types of benefits to include and who qualifies. CMS is increasing oversight to ensure these benefits are supported by evidence showing they can improve or maintain a member’s health or function.

SSBCI represents a shift in Medicare Advantage toward whole-person care; addressing more than just medical needs.

What Is VBID?

The Value-Based Insurance Design (VBID) Model, launched by the CMS Innovation Center, allowed participating Medicare Advantage plans to align cost-sharing and benefits with the clinical value of care. The goal was to lower barriers to high-value care (like preventive services or chronic disease management) while discouraging unnecessary spending.

VBID gave participating plans flexibility to reduce copays, expand supplemental benefits, and even test hospice care integration within MA. These features often targeted individuals with chronic illnesses, low income, or those living in underserved areas.

However, VBID was a demonstration model, not a permanent part of Medicare. In 2025, CMS announced it will end the VBID Model after determining that program costs to Medicare were higher than anticipated. While the model is ending, many of its design ideas; like targeted cost-sharing and flexible benefits, are expected to influence future MA benefit structures.

SSBCI vs. VBID: A Quick Comparison

Why It Matters

Both programs reflect a growing focus on integrated, person-centered care in Medicare Advantage.

• For beneficiaries: SSBCI can provide meaningful extra help for daily living and health support, but eligibility rules apply. Not everyone in an MA plan will qualify.
• For VBID participants: The model’s end may change how some plan benefits are structured in 2026, but many innovations are expected to remain.
• For all MA enrollees: When comparing plans, look beyond premiums and copays. Review whether a plan offers SSBCI or other supplemental benefits that fit your personal needs.

Always review your plan’s Summary of Benefits and Evidence of Coverage to see if SSBCI options are available, and confirm your eligibility with the plan.

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SSBCI and VBID have both pushed Medicare Advantage toward smarter, more holistic care. While VBID will conclude in 2025, SSBCI continues to grow; helping address many factors that shape health outcomes. Together, they represent Medicare’s evolving goal: not just to pay for medical care, but to help beneficiaries live healthier, more independent lives.

Humana Medicare 2026 OTC Benefits: How to Use and Access Them

Many Humana Medicare Advantage (Part C) plans include an over-the-counter (OTC) allowance to help members save on everyday health items. Fortunately, Humana Medicare 2026 OTC benefits provides members more ways to maintain their health while managing out-of-pocket costs.

What the OTC Benefit Covers

Humana’s OTC benefit allows members to buy non-prescription health and wellness products at no cost, up to a set allowance. Covered items typically include:

• Pain relievers and cold medicines
• Vitamins and supplements
• Dental care items like toothbrushes and toothpaste
• First-aid and wound-care supplies
• Digestive aids and bladder-control products

Depending on the plan, members may receive a monthly or quarterly allowance to spend. Some plans offer rollover options, while others require that unused funds be used within the benefit period.

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How to Access Your OTC Benefit

1. Confirm Eligibility – Log into your MyHumana account or review your Summary of Benefits to confirm your plan includes an OTC allowance. You can also call the Member Services number on your Humana ID card.
2. Know Your Allowance – Find out how much you receive and how often it renews. Available benefits vary by plan and region.
3. Shop for Eligible Items – You can use your OTC funds in several ways:
   • Humana Spending Account Card – Many plans load your allowance onto a prepaid card you can use at participating retailers.
   • Mail Order or Online Catalog – Some plans require ordering through CenterWell Pharmacy’s OTC catalog or online store.
4. Use It Before It Expires – Most allowances expire at the end of each benefit period or at year-end. Check your balance often to avoid losing unused funds.

Tips to Maximize the Benefit

• Review Plan Changes Annually: OTC benefits and amounts can change each year. Always read your Annual Notice of Change (ANOC) each fall.
• Shop Early and Smart: If mail order is required, place orders early to allow for shipping time.
• Combine Benefits: Some Humana plans that include Healthy Options or grocery allowances encourage clients to take advantage of all available extras.
• Keep Receipts: If questions arise, documentation helps confirm eligible purchases.
• Ask for Help: Members can contact Humana Member Services or their licensed agent for guidance.

Why This Benefit Matters

Humana’s OTC benefit helps reduce the cost of everyday health items, adding value to Medicare Advantage coverage. For 2026, these allowances highlight Humana’s focus on affordability and wellness. When clients understand and use these benefits fully, they save money, improve their health, and feel more satisfied with their plan.

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Understanding Coordinated Care: How It Improves Health

When it comes to your health, it’s not uncommon to see several doctors, specialists, or therapists over time. But have you ever wondered who’s making sure everyone is on the same page about your care? That’s where understanding coordinated care comes in. This is an approach designed to keep healthcare connected, organized, and focused on the patient as a whole.

What Is Coordinated Care

Coordinated care is a healthcare model that ensures all members of the care team; from primary care providers to specialists, hospitals, and even pharmacists, work together to manage overall health. The goal is simple: to deliver high-quality care that meets healthcare needs while reducing confusion, delays, and unnecessary costs.

Instead of treating each health concern in separately, coordinated care looks at your entire health picture. It’s a team-based, patient-centered approach that emphasizes communication and collaboration across all your healthcare providers.

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How Coordinated Care Works

In a coordinated care system, one provider (often your primary care physician or a dedicated care manager) takes the lead in managing your treatment plan. This person acts as your main point of contact and ensures that:

• Providers share test results and medical records to forma treatment plan
• Treatments don’t overlap or conflict
• You understand your medications and next steps
• Your transition between care settings; such as from hospital to home, goes smoothly

This kind of teamwork helps prevent medical errors, unnecessary repeat tests, and medication mix-ups that can happen when care is fragmented.

Examples

• A person living with diabetes might see a primary care doctor, an endocrinologist, and a nutritionist. In coordinated care, these professionals communicate regularly to align medications, diet recommendations, and follow-up visits.
• After a hospital discharge, a care coordinator might help schedule follow-up appointments, review discharge instructions, and ensure the patient fills their prescriptions; reducing the chance of readmission.
• Many Medicare Advantage and Accountable Care Organizations (ACOs) use coordinated care models to deliver more efficient and effective care for members.

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Why Coordinated Care Matters

Coordinated care isn’t just about organization; it’s about better outcomes. When providers share information and work together, you benefit from:

• Improved overall health
• Fewer hospital visits
• Lower out-of-pocket costs
• Greater satisfaction with your care

Most importantly, it ensures that care reflects your personal goals, preferences, and lifestyle because no one’s health journey looks the same.

Coordinated care is about putting the patient back at the center of the healthcare experience. By connecting the dots between your doctors, specialists, and support services, coordinated care leads to smarter, safer, and more compassionate healthcare.

Whether you’re managing a chronic condition or just want a smoother healthcare experience, coordinated care helps ensure that every part of your health story fits together the way it should.

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Medicare as Primary Insurance

When you turn 65 or qualify for Medicare due to disability, one of the most important things to know is whether Medicare becomes your primary or secondary insurance. Understanding Medicare as primary insurance helps avoid billing issues and unexpected out-of-pocket costs.

What Does “Primary” Mean

The primary payer is the insurance that pays your medical bills first. The secondary payer may cover costs that the primary insurance doesn’t pay; such as deductibles, coinsurance, or copays.
When Medicare is your primary insurance, your healthcare providers bill Medicare first. Once Medicare pays its share, any remaining balance may be sent to your secondary insurance, such as an employer plan or Medigap policy.

When Medicare Is Primary

Medicare typically pays first in these situations:

1. You’re retired and not covered by active employer insurance.
   Once you stop working and lose active coverage from an employer, Medicare becomes your primary insurance.
2. You have a small employer plan (fewer than 20 employees).
   If you’re still working or covered under a spouse’s small employer plan, Medicare pays first.
3. You have retiree coverage.
   Retiree insurance or COBRA coverage always pays after Medicare.
4. You have no other insurance.
   If Medicare is your only health coverage, it’s automatically primary.
5. You’re covered by Medicaid.
   Medicaid is always the payer of last resort, so Medicare pays first.

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When Medicare Is Secondary

In some cases, Medicare may pay after another insurance plan:

• You or your spouse are actively working for an employer with 20 or more employees, and you’re covered under that employer’s health plan.
• You’re receiving workers’ compensation or have a claim covered under no-fault or liability insurance.
• You’re under age 65 and have employer coverage due to disability, and the employer has 100 or more employees.

In these situations, your employer or other insurance must pay first, and Medicare acts as a secondary payer.

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Why It Matters

Knowing when Medicare is primary ensures your medical claims are processed correctly. If you enroll in Medicare but fail to tell your other insurer, or vice versa, you could face denied claims or late enrollment penalties.
Always confirm your coverage status with both Medicare and your employer’s benefits administrator to avoid costly mistakes.

Medicare’s role; whether it’s primary or secondary, depends on your work status, the size of your employer, and any additional coverage you may have.
If you’re nearing retirement or changing jobs, take time to review how your coverage coordinates. Doing so helps ensure smooth billing and gives you peace of mind knowing your healthcare costs are properly covered.

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Understanding Medicare Formulary Exceptions — And How to Get One

When you’re enrolled in a Medicare Part D or Medicare Advantage plan with prescription drug coverage, your plan covers medications according to the plan’s formulary; the list of drugs the plan agrees to cover. What happens if the prescribed medication isn’t on that list, or it’s coverage has restrictions? That’s when understanding Medicare formulary exceptions becomes very important.

A formulary exception is a special request made by a plan enrollee with supporting information from their doctor or directly from their doctor for a plan to cover a drug that’s not included in the plan’s formulary, or to waive certain restrictions, like prior authorization or step therapy.

When You Might Need a Formulary Exception

You might need to request an exception if:

• Your medication isn’t on your plan’s formulary.
• Your plan requires step therapy, meaning you must first try a different (and usually less expensive) drug before the one your doctor prescribed.
• There’s a quantity limit, and your doctor believes you need more than what’s allowed.
• Your plan makes a formulary change mid-year, and the drug you rely on is no longer covered.

If your doctor determines that no covered drug will work as well for your condition, or that other alternatives could cause adverse effects, you can request an exception.

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How to Request a Formulary Exception

Here’s the process step-by-step:

1. Talk to your doctor first. Your prescribing doctor must support your exception request and provide medical justification explaining why the specific drug is necessary.
2. Submit the request form. You (or your doctor) will complete your plan’s Coverage Determination Form. Most plans provide this form online or through their customer service department.
3. Wait for the plan’s decision.
   • The plan must make a decision within 72 hours for standard requests.
   • If your doctor believes you need the medication sooner due to your health, you can ask for an expedited (fast-track) review, which requires a decision within 24 hours.
4. If denied, you can appeal. You have the right to appeal the decision through multiple levels if necessary. Your doctor can help provide additional medical documentation to strengthen your case.

Tips for a Successful Exception Request

• Provide clear medical justification. The more detailed your doctor’s explanation, the better.
• Submit supporting evidence. Include prior medical history, records of failed alternative treatments, or side effect reports.
• Act early. If you know your plan doesn’t cover a medication, start the exception process before you run out of your current supply.

Formulary exceptions can seem complicated, but they exist to ensure you have access to the medications you truly need. Working closely with your doctor and following your plan’s process carefully can make all the difference.

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If you’re unsure how to begin, contact your plan’s member services department; they can walk you through the steps and provide the necessary forms. Being proactive can help you avoid treatment interruptions and unnecessary stress.

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Why Medicare Star Ratings Matter – Understanding Their Importance

When comparing Medicare Advantage or Part D prescription drug plans, you’ll see a “star rating” next to each one. These ratings aren’t just numbers; they reflect the overall quality and performance of a plan. Knowing why Medicare star ratings matter can help beneficiaries make a more confident, informed choice.

What Are Medicare Star Ratings

Each year, the Centers for Medicare & Medicaid Services (CMS) rates Medicare Advantage (MA) and Part D plans on a 1-to-5-star scale, with 5 stars being excellent and 1 star being poor.

CMS evaluates plans based on key measures such as:

• Preventive care and managing chronic conditions
• Member satisfaction and customer service
• Medication safety and accuracy of drug pricing
• Handling of complaints and appeals

These ratings help beneficiaries compare plan quality; not just costs.

Why Star Ratings Matter to Beneficiaries

1. Quality Over Cost
   A low monthly premium might look appealing, but a lower-rated plan could have poorer customer service or fewer care management programs. Star Ratings help you see the bigger picture.
2. Better Health Outcomes
   High-rated plans generally perform better in preventive care, chronic condition management, and prescription safety leading to improved member health.
3. Special Enrollment Advantage
   If a 5-star plan is available in your area, you can use the 5-Star Special Enrollment Period to switch once a year, even outside regular enrollment periods.

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Why Star Ratings Matter to Carriers

For insurance carriers, these ratings are more than just feedback — they directly affect their business.

• Financial Rewards: CMS provides quality bonus payments to plans with ratings of 4 stars or higher. These bonuses can help carriers enhance benefits, reduce premiums, and remain competitive.
• Reputation and Market Growth: A higher-rated plan attracts more enrollees. Consumers often view Star Ratings as a trusted indicator of quality and satisfaction.
• Compliance and Accountability: Consistently low ratings can lead to penalties or even removal from the Medicare program. This motivates carriers to continuously improve service, communication, and care coordination.

In short, the Star Rating system drives both accountability and quality improvement for carriers and members alike.

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The Bottom Line

Medicare Star Ratings serve an important purpose for everyone involved. They help beneficiaries choose better plans, encourage carriers to maintain high standards, and ensure that Medicare funds support quality care.

When reviewing plans, remember; the stars tell a story about value, performance, and member experience. Taking time to understand them can make an important difference in satisfaction with healthcare coverage.

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Reasons for MA Plan Cuts – What’s going on

Recently, many insurers are pulling back or dropping Medicare Advantage plans in certain counties. Many Medicare advantage carriers are reducing offerings. This is especially true for PPO plans, which tend to be less restrictive for patients, but also costlier/riskier for insurers. Here’s a breakdown of the reasons for MA plan cuts and why some Medicare Advantage (MA) plans are leaving the market, what it means for enrollees, and how to prepare.

Why Some Medicare Advantage Plans Are Leaving the Market

In 2025 and beyond, several major insurers are scaling back or exiting certain Medicare Advantage (MA) markets. Companies like UnitedHealthcare, Humana, and Aetna are discontinuing specific plans or leaving select counties, affecting hundreds of thousands of beneficiaries. So, what’s driving these exits and what does it mean for Medicare enrollees?

Rising Costs and Slower Reimbursements

The main driver behind these exits is financial pressure. Health care costs; doctor visits, hospital stays, and prescription drugs continue to rise. Meanwhile, the Centers for Medicare & Medicaid Services (CMS) has limited how much funding increases for MA plans each year.

When reimbursement rates don’t keep pace with actual medical spending, insurers are forced to make tough decisions. Some reduce coverage areas; others leave markets entirely. The challenge is even greater in rural counties, where fewer enrollees mean higher per-member costs and less opportunity to spread financial risk.

Increased Regulation and Administrative Burdens

Medicare Advantage plans are subject to strict federal oversight. CMS star ratings, which measure quality and satisfaction, directly affect plan payments and bonuses. Plans with low ratings can face penalties or reduced funding.

New rules around prior authorization, marketing practices, and network adequacy have also added administrative costs. While these policies aim to protect consumers, they make operating certain plans more expensive and complex; especially for smaller carriers.

Shrinking Margins and Risky Plan Types

Preferred Provider Organization (PPO) plans, which allow greater provider flexibility, are especially expensive for insurers to run. In response, many companies are narrowing their focus to Health Maintenance Organization (HMO) plans with tighter networks and lower costs.

However, even with these adjustments, many insurers report that the combination of higher utilization, slower reimbursements, and increased regulation has made some plans unsustainable. As a result, certain counties are seeing fewer plan options for 2026.

Cutting Back on Benefits

To stay competitive and manage costs, insurers are also reducing extra benefits that have become popular selling points for Medicare Advantage plans.

Perks such as dental, vision, hearing, over-the-counter allowances, and fitness memberships are being scaled back or dropped altogether. Some plans have increased copays for specialists, raised out-of-pocket maximums, or restricted drug formularies.

While these changes help insurers control spending, they can leave beneficiaries with fewer incentives to stay on a plan—prompting more people to explore other options like Original Medicare with a Medigap supplement.

What This Means for Beneficiaries

If your Medicare Advantage plan is ending or changing benefits, you’ll receive an Annual Notice of Change (ANOC) this fall. It’s important to read this document carefully. You may find that your premiums, networks, or covered benefits are changing even if your plan remains available.

Here’s what to watch for:

• Fewer local plan options—especially in smaller or rural markets.
• Higher out-of-pocket costs due to benefit reductions or network changes.
• Provider access changes as plans narrow their networks.
• Reduced extra benefits, such as dental, vision, and wellness perks.

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If your plan is leaving your area entirely, you’ll qualify for a Special Enrollment Period (SEP) to choose a new plan or return to Original Medicare.

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What You Can Do

1. Review your ANOC early to understand all upcoming changes.
2. Compare new plans on Medicare.gov or with a licensed agent to see what’s available in your ZIP code.
3. Look beyond the premium. Consider total out-of-pocket costs, copays, and your provider network.
4. Verify your prescriptions. Ensure your medications are still covered under the plan’s formulary.
5. Explore Medigap and Part D options if you want more stability or broader provider access.

The Bottom Line

Medicare Advantage remains a strong and growing program, but rising costs and tighter reimbursement rules are forcing insurers to reassess their participation. Many are choosing to leave certain counties or reduce extra benefits to stay financially viable.

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For beneficiaries, staying informed is key. Review your plan each year, compare options carefully, and don’t assume your current benefits will stay the same. A little preparation can help avoid surprises and ensure you continue to get the coverage and care you need.

Medicare Part B Costs 2026

Medicare Part B helps cover medically necessary outpatient services, doctor visits, preventive services, medical equipment, and more. Because like many aspects of health care, its costs change annually, We will discuss the Medicare Part B costs 2026. beneficiaries and future enrollees need to know what’s ahead.

Below, we explore the projected premiums, deductibles, income-based surcharges (IRMAA), and strategies for planning.

What’s Covered by Part B & Basic Costs

Before diving into 2026, here’s a quick recap of how Part B costs typically work:

• You pay a monthly premium for Part B (unless you qualify for assistance).
• You also pay a yearly deductible before Medicare pays (for most services).
• After meeting the deductible, Medicare generally covers 80% of approved costs for covered outpatient services; you’re responsible for the remaining 20% coinsurance (unless another plan helps).
• If your income is above certain thresholds, you may pay an extra surcharge (IRMAA).
• Costs can vary based on where you live, your coverage options (like Medigap or Medicare Advantage), and your income.

These rules remain consistent, even as dollar amounts shift over time.

Projected Part B Premium in 2026

According to the Medicare Trustees’ projections and other financial analysts, the standard Part B monthly premium is expected to rise from $185 in 2025 to $206.50 in 2026 an increase of $21.50, or roughly 11.6%.

That jump would be the largest single-year dollar increase in recent years.

It’s crucial to note: this “standard” premium applies to beneficiaries without additional income-based surcharges (i.e. those whose incomes fall under the IRMAA thresholds). Those with higher incomes will pay more.

Expected Part B Deductible in 2026

While the exact deductible for 2026 will not be finalized until closer to year-end 2025, current projections suggest it may rise from $257 in 2025 to $288 in 2026.

That would be a roughly 12% increase in the amount beneficiaries pay out of pocket before Medicare starts covering your outpatient services.

Some Medigap (supplemental) plans cover the deductible; others require you to pay it yourself, so an increase could matter more to those on certain Medigap plans.

Income-Related Monthly Adjustment Amount (IRMAA) for 2026

One of the most significant cost levers in Medicare is the IRMAA surcharge: higher-income beneficiaries pay extra on top of the base premium. Here’s what’s projected for 2026:

• The 2026 IRMAA brackets and surcharge amounts are based on modified adjusted gross income (MAGI) from your 2024 tax return.
• The income thresholds (for moving among surcharge tiers) are expected to be indexed upward (adjusted for inflation) for 2026.
• The average surcharge increases for Part B are projected to be modest; around 1.04%.

Because of IRMAA, two people in the same city with different incomes might pay very different Part B amounts.

Why Are Costs Rising

Several forces contribute to rising Medicare Part B costs:

1. Medical inflation and utilization – Outpatient services, physician-administered drugs, diagnostics, and usage of health services often rise faster than general inflation.
2. Aging population / higher demand – As more retirees enter Medicare and health care needs grow, the burden on the system increases.
3. Cost shifting – Higher-income beneficiaries absorb more of the cost via IRMAA, but base premiums still have to cover a portion of system-wide costs.
4. Policy adjustments & fund dynamics – Adjustments to how much premiums are allowed to cover, budget pressures, and funding decisions all play a role.
5. Legislative changes – New laws affecting drug pricing, Medicare rules, and benefit design indirectly affect Part B costs over time.

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What It Means for Beneficiaries

• Budget impact: That extra $21.50 per month may absorb a significant chunk of any Social Security cost-of-living adjustment (COLA). Indeed, projections show much of retirees’ COLA gains may be eaten by higher health costs.
• Planning ahead: If your income is near an IRMAA threshold, small changes (e.g. capital gains, extra work income, withdrawals) could push you into a higher bracket.
• Review your coverage: Supplemental (Medigap) or Medicare Advantage plans may mitigate some out-of-pocket costs. If your Medigap plan covers the Part B deductible, the increase matters more.
• Appeal or exemption: If your income decreases substantially due to life events (e.g. retirement, widowhood), you may be able to appeal IRMAA adjustments.
• Stay informed: Final Medicare pricing is announced in late 2025. Propose your budget accordingly but expect adjustments.

Tips to Manage the Cost Increase

1. Estimate your 2024 MAGI now — knowing whether you might cross an IRMAA threshold will help with tax planning or withdrawals.
2. Delay or stagger income where possible — if legally and financially feasible, deferring income from 2024 may help you stay lower in the IRMAA tiers.
3. Choose the right supplemental plan — some Medigap policies cover the Part B deductible or reduce your coinsurance burden.
4. Stay within the initial enrollment windows — avoid late enrollment penalties, which add to cost burdens.
5. Appeal IRMAA where applicable — if you experience life-changing events, you may qualify for exceptions.
6. Watch your investments and gains — high capital gains or distributions in 2024 could unexpectedly push your MAGI upward.

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Bottom Line

Based on current projections:

• The standard Part B premium in 2026 may reach $206.50 per month, up from $185 in 2025.
• The deductible is expected to rise to about $288.
• Income-based surcharges (IRMAA) may add considerably more for higher earners.
• The increase is sizable and could erode a portion of any Social Security increase.
• Planning ahead; particularly regarding your 2024 income, can help reduce the surprise.

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Which Vaccines Does Medicare Cover

Vaccinations are an important part of preventive healthcare, especially for older adults who may be at higher risk of serious illness. Fortunately, Medicare provides coverage for many common vaccines, but which vaccines does Medicare cover? Additionally, knowing which part of Medicare covers what can help beneficiaries avoid surprise costs.

Vaccines Covered by Medicare Part B

Medicare Part B covers certain vaccines that are considered medically necessary for disease prevention. These include:

• Flu shot (Influenza vaccine): Covered once per flu season, and sometimes more if medically necessary.
• Pneumococcal vaccine: Helps prevent pneumonia and other infections. Medicare covers two different pneumococcal shots at no cost when given at least one year apart.
• Hepatitis B vaccine: Covered for beneficiaries at medium or high risk (such as those with diabetes, liver disease, or certain occupational exposures).
• Vaccines needed due to injury or exposure: For example, if you’re exposed to rabies or step on a rusty nail and need a tetanus shot, Medicare Part B covers it.

There’s no deductible or copayment for these vaccines if you receive them from a provider who accepts Medicare assignment.

Vaccines Covered by Medicare Part D

Medicare Part D (prescription drug coverage) handles most other commercially available vaccines that are not covered by Part B. This includes:

• Shingles (Herpes Zoster) vaccine
• Tetanus, Diphtheria, and Pertussis (Tdap) vaccine when not related to an injury
• RSV (Respiratory Syncytial Virus) vaccine for older adults
• Travel vaccines, such as those for hepatitis A or typhoid, depending on your plan

Part D plans must cover all vaccines recommended by the Centers for Disease Control and Prevention (CDC) that aren’t already covered by Part B. Since 2023, beneficiaries pay no out-of-pocket costs for these recommended vaccines under Part D.

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Why Staying Up to Date Matters

Getting the right vaccines can help prevent hospitalizations and serious illness. With Medicare’s expanded coverage, beneficiaries can stay current on vaccinations at little to no cost. It’s always best to check with your provider or Part D plan to confirm coverage before receiving any vaccine

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Medicare makes it easier than ever to stay protected. Part B covers flu, pneumonia, Hepatitis B (for those at risk), and vaccines needed due to injury, while Part D covers all other recommended vaccines; often at no cost.

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Common Medicare Beneficiary Mistakes

Medicare can be confusing, especially with its many rules and enrollment periods. Unfortunately, even small mistakes can lead to coverage gaps or lifetime penalties. Here are some of the most common Medicare beneficiary mistakes and missteps to avoid.

Missing Your Initial Enrollment Period

Your Initial Enrollment Period (IEP) is your first chance to enroll in Medicare. It starts three months before your 65th birthday, includes your birthday month, and ends three months after. Waiting too long to sign up can delay your coverage and lead to permanent late enrollment penalties — especially if you don’t have other creditable insurance.

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Assuming COBRA or Retiree Coverage Lets You Delay Medicare

If you have COBRA or retiree insurance, don’t assume it allows you to postpone Medicare. COBRA is not creditable coverage for delaying Part B or Part D. Failing to enroll when first eligible can leave you uninsured and subject to lifetime penalties once you do sign up.

Not Enrolling While Working for a Small Employer

If you’re still working and your company has 20 or fewer employees, Medicare becomes your primary insurance, not your employer plan. Failing to enroll in Medicare on time could mean denied claims and unexpected bills.

Ignoring the Need for a Part D Drug Plan

Even if you don’t take prescriptions, you should enroll in a Part D plan when first eligible. Without it, you’ll face a permanent late enrollment penalty once you do sign up, and you’ll have to wait until the next enrollment period for your coverage to start. Many beneficiaries choose an inexpensive plan simply to avoid future penalties.

Confusing Medigap Enrollment Rules

Unlike Medicare Advantage or Part D, Medigap doesn’t have an annual election period. Your one-time Medigap Open Enrollment Period begins when you enroll in Part B. During these six months, you can get a Medigap plan with no health questions — miss it, and medical underwriting could apply later.

Paying the Part B Deductible Too Soon

Some providers mistakenly request the Part B deductible before Medicare processes your claim. Always wait until Medicare applies the deductible to the correct bill to avoid confusion or overpayment.

Bottom Line

Understanding Medicare’s timelines and coverage rules can save you from penalties, gaps and unnecessary stress. Taking the time to review coverage options and asking your agent questions before you enroll helps you get the most out of your benefits.

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