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Efforts are still underway to smooth out the hiccups to the initial rollout of the updated COVID-19 vaccines among health insurers and providers.
Americans across the United States, including Hawaii residents, encountered insurance snags while trying to get the COVID-19 vaccines through the commercial market last week. Most private insurers, however, as well as Medicaid and Medicare, are required to cover the vaccines without cost-sharing, according to U.S. Health and Human Services.
The Centers for Disease Control and Prevention on Sept. 12 recommended everyone ages 6 months and older get the updated COVID-19 vaccines to protect against potentially serious outcomes of illness this fall and winter.
In Hawaii some HMSA customers were informed the following week by CVS Pharmacy at local Longs Drugs stores that the vaccine was not covered and they would have to pay nearly $200 out of pocket.
As a result, many decided to postpone their COVID-19 shots.
One such customer, Penelope Higa of Aiea, said she was able to get her COVID-19 vaccine Sept. 22 with HMSA Akamai Advantage coverage at her local Longs Drugs.
Dr. Stefanie Park, HMSA’s vice president and chief medical officer, said technical matters behind those issues have been resolved.
HMSA’s system has been updated, she said, and is actively receiving claims.
“We are receiving feedback from our members and continue to work with our pharmacy partners locally,” said Park in a statement. “We received confirmation that most have updated their systems to send us claims, and some are still working to update their systems. We have received confirmation that the pharmacies have updated their workflows and will not charge our members for this covered benefit. Pharmacies will service and reimburse our members for the newest COVID-19 vaccine as it is available in our community.”
If members were required to pay out-of-pocket costs during this brief period, they can seek reimbursement within 30 days at the pharmacy where they received their vaccination — and should bring their receipt, if possible, to expedite the process.
CVS and Walgreens began offering appointments for the updated COVID-19 vaccines at their pharmacies last week.
“Walgreens is committed to ensuring no patient pays and everyone who is eligible and wants a vaccine receives one,” said the retailer in a statement.
Kaiser on Wednesday began offering updated COVID-19 vaccines from Pfizer at its clinics statewide, but to Kaiser members only as part of routine vaccination coverage.
Coverage required
The U.S. Department of Health and Human Services, meanwhile, reminded insurers that the Affordable Care Act requires most forms of private health insurance to cover any vaccine recommended by the Advisory Committee on Immunization Practices — such as the updated COVID-19 vaccine — without cost-sharing at an in- network provider.
Some rare exceptions include grandfathered plans or short-term insurance plans.
Medicaid and Medicare must also cover the COVID-19 vaccines.
In a letter issued last week, HHS Secretary Xavier Becerra reminded insurers of their legal obligations and that coverage was required upon the approval and authorization of the vaccines by the Food and Drug Administration on Sept. 11.
“As you know, this is the first season where COVID-19 vaccines are being distributed in the traditional health care distribution channels,” he wrote. “We began preparing for this over a year ago to ensure a smooth transition for the updated COVID-19 vaccines.”
These requirements were detailed in a July 13 letter by Centers for Medicare and Medicaid Services Administrator Chiquita Brooks-LaSure, who had urged insurers to be prepared for the fall vaccination campaign.
HMSA said it remains aligned with federal guidance and requirements.
“We understood the necessity of ensuring our members could receive the vaccine and had been working on bringing our systems up to date,” said Park in a written response. “However, we ran into many of the same technical coding issues other health plans experienced across the nation. We worked as quickly as we could internally to set our rates and externally with our pharmacy partners to enable our members to access the updated COVID-19 vaccine.”
While most HMSA commercial plans cover the COVID-19 vaccine 100%, she said, there are a small number of commercial plans where the employer has an exemption from the government and has decided not to cover these vaccinations.
Members with questions can call the HMSA customer service number on their cards for assistance.
Most private insurance plans should cover the COVID-19 vaccines without copays, according to Hannah Green, the American Lung Association’s national senior director of health policy.
Insurance snafus have been a nationwide issue, said Green, and ALA hopes they do not deter people from getting the updated COVID-19 vaccine for protection.
“That’s 100% what we don’t want to happen,” said Green. “ALA is recommending everyone 6 months and older gets vaccinated. We want to make sure everyone gets covered regardless of insurance. We know cost is a huge barrier to vaccination, so we don’t want that to be a huge issue for everyone.”
ALA is concerned for those at high risk of severe illness, including people with chronic lung diseases and those who are immune-compromised.
“We want to make uptake as high as possible to protect those groups, to make sure we reduce severe illness and death as much as possible,” she said.
On Wednesday the state Department of Health reported a daily average of 111 new COVID-19 cases and average statewide positivity of 9.6% over the week, which were lower than previous weeks.
Another 10 COVID-19-related deaths were reported, bringing the state’s COVID-19 death toll to 2,025.
But confusion over insurance coverage is not the only challenge in accessing COVID-19 vaccines.
Some residents were able to get vaccine appointments at a nearby pharmacy while others were not.
A recent search for COVID-19 vaccines using a Honolulu ZIP code at CVS yielded few available appointments within a 5-mile radius. An earlier search a few days earlier found the only appointments available were in Haleiwa and Waianae.
Some residents reported their appointments were canceled at the last minute due to lack of vaccines.
Becerra in his letter asked insurers to consider any and all ways to reduce barriers to coverage.
“In closing, I would remind you that we should be completely aligned in our goals of getting everyone the updated COVID-19 vaccine,” he wrote. “According to CDC, for every 10,000 vaccinations given to people 65 and over last winter, about 40 hospitalizations are prevented. With claims rejections in the thousands each day, we are missing opportunities to save lives together.”
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COVID vaccine coverage
>> Medicaid: Covered with no out-of-pocket costs. Stipulated by the American Rescue Plan Act.
>> Medicare: Covered by Medicare Part B without cost-sharing. Stipulated by the CARES Act.
>> Tricare: Covered for all beneficiaries with no out-of-pocket costs.
>> Private insurance: Covered with no out-of-pocket costs through in-network providers under the Affordable Care Act.
>> No insurance: Adults can access free COVID-19 vaccines through CDC’s Bridge Access Program, which includes participating community health centers and retail pharmacies. Uninsured, underinsured children can get free vaccines through the Vaccines for Children program.
Source: COVID Vaccine Education and Equity Project
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