Access to new Covid-19 vaccines delayed for Vermonters on Medicaid

Updated at 5:15 p.m.

As Vermonters began getting the new Covid-19 vaccine by appointment at some pharmacies this week, a billing glitch became a frustrating barrier for those seeking the shot who are covered by the state-run Medicaid program. 

“Some payers are still updating their systems and may not yet be set up to cover the updated Covid-19 vaccines,” said Matt Blanchette, a spokesperson for CVS, in a written statement. The problem is coming up across the country, he added. 

However, in Vermont, the issue appears to only be affecting those covered by Green Mountain Care, the state’s Medicaid health insurance program for lower-income adults and for most children, which provides pharmaceutical coverage for roughly 30% of all Vermonters.

The update to Vermont Medicaid’s billing database should be completed by Friday, which should resolve the issues people have been having, according to Lisa Brouillette Hurteau, director of pharmacy at the Department of Vermont Health Access.

More than a week since federal approval of the new Moderna and Pfizer vaccines, Vermonters are accessing them on a limited basis, mostly through appointments made online at pharmacies owned by national chains CVS and Walgreens. More pharmacies, both chains and independents, are expected to have them over the next week. 

Federal and state health authorities are recommending that everyone six months and older get a new version of Covid-19 vaccine, which like the annual flu vaccine is now formulated to target the most commonly circulating virus strains. The shots are supposed to be available without cost to insured individuals, with federal funds available to reimburse pharmacies and healthcare providers for vaccines for the uninsured. 

However, people with Vermont Medicaid insurance who made appointments to get the latest vaccine, sometimes far away from their homes, found upon arrival that the pharmacy was not able to bill for it, leaving them with the choice to pay full price — quoted at $150 — or come back later. It’s unclear how many people were affected, but calls to several pharmacies suggest that it has been at least a dozen and likely more. 

Meanwhile, billing codes are all up to date for pharmacies and healthcare providers for BlueCross BlueShield of Vermont, said spokesperson Rebecca Copans.  

“We encourage Vermonters to get both their flu and covid shot as soon as they can — both are zero out of pocket cost for our members both at the pharmacy and their provider office,” she said in an email.

The billing database that pharmacies link to at the point of sale for Vermont Medicaid is run by a large private contractor, Change Healthcare —- owned since last year by healthcare services giant Optum. 

The database is updated weekly overnight between Thursday and Friday with new codes that identify specific drugs and their dosages, Brouillette Hurteau explained. The unique code that identifies the newly approved vaccines by Pfizer and Moderna was not included in last week’s update, but will be added by tomorrow, she said. 

“We were hoping they would be added before now,” she said. “I don’t know why they didn’t get loaded until this week.”

Once updated, the billing will be allowed retroactively to Sept. 11, Brouillette Hurteau said. That’s why the delay should not affect anyone who is getting the new Covid-19 shot through a healthcare provider’s office, which generally has a longer billing cycle. 

The federal Department of Health and Human Services acknowledged in a public statement that insurers of all kinds have run into challenges in recent days despite several months of preparation for the first round of fully commercialized Covid-19 vaccines.

“We are aware that some consumers have experienced unexpected insurance coverage denials at the point of service,” the statement said. All insurers were required to begin providing no-cost coverage of the new Covid-19 vaccines on Sept. 11, the day they were approved. 

However, the Center for Medicare and Medicaid Services did not provide the vaccine pricing, codes or descriptions to payors officially until Thursday, Sept. 14, as the new vaccines started to be shipped out.

Even once this issue is resolved, children covered by Vermont Medicaid are not likely to be able to get their vaccines at a pharmacy. So far few pharmacies in the state, if any, are enrolled in the Vermont Child Vaccine Program, which is a requirement for reimbursement, Brouillette Hurteau said. Any primary care provider serving Medicaid patients would be part of the program and able to provide the vaccine, she said.

The Vermont Department of Health has 1,500 doses that it is sending out to primary care providers around the state, said spokesperson Katie Warchut in an email. Availability will vary depending on whether the provider has also made a separate order that may have arrived earlier, she said. 

“Since this is a new vaccine formulation, the supply is limited right now, but vaccine is expected to be widely available at provider practices and pharmacies throughout the state in the coming weeks,” she said.