The latest COVID vaccine formulations are out and designed to counter the virus’s latest mutations. Health experts say it’s important to get vaccinated now to be ready for this fall and winter — when cases could increase more than they already have.
Some people who have tried to get vaccinated have come up against new obstacles, though. That’s because this is the first round of COVID vaccinations relying mostly on the usual health insurance and provider networks as opposed to the government.
There was a time before now when getting a COVID vaccine meant figuring out the nearest place that had one and making an appointment, or sometimes even just walking in. The reason is because the federal government was footing the bill and distributing the vaccines.
But Congress did not authorize more funding, and COVID vaccinations are now going through the commercial health care system. Cue the problems.
“I’ve been turned away twice for vaccine appointments that I had,” said Cynthia Cox, who lives in Washington, D.C. “Although I was willing to pay cash up front, my insurer kept me from being able to get the vaccine, because it was an out-of-network pharmacy.”
Cox also happens to be a health care policy researcher at the Kaiser Family Foundation. The out-of-network issue has been one of the stumbling blocks, she said.
“Insurers don’t have to pay for out-of-network care,” Cox said. “But, if that preventive service is not available in network, then they do have to allow you to go out of network and pay for it in full.”
The question is what constitutes “not available” when dealing with COVID vaccine doses. There were initial supply constraints in parts of the country that affected in-network providers.
“The supply issues and the out-of-network coverage issues are going hand in hand” Cox said. “If there’s no vaccine in-network, then technically you should be able to go out-of-network to get it.”
But if the shortage is temporary, Cox said, that may have left insurance companies with enough wiggle room to deny out-of-network visits.
Another issue is time. Regulators approved the latest COVID vaccine formulations only on Sept. 11. Insurers had to rush to make them available.
The usual timeline is longer, noted Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.
“Plans are given a bit of time between when the vaccine is approved and recommended for use and when they actually have to cover it under their plan,” she said.
Without the head start, some health insurers’ complex payment systems were not updated fast enough and patients got turned away.
This got the attention of federal regulators. Health and Human Services Secretary Xavier Becerra met virtually with health care industry leaders on Wednesday.
“The meeting went very well. It was very positive and collaborative in nature,” said Jenny McGuigan Babcock, the senior vice president for medicaid policy at the Association for Community Affiliated Plans, a trade group. “The Secretary’s office and officials, along with the health plan associations, had been working pretty intensively for the prior week to ensure that problems were ironed out.”
Industry representatives say that — for the most part — they have been and they must be, because the companies are legally required to provide COVID vaccines at no cost to patients.
