A Covid vaccine denied
A Connecticut woman loses her place in line because of a billing issue.
The rollout of the coronavirus vaccine has been plagued with foreseeable and preventable problems, from expiring doses thrown in the trash to communities of color ignored and forgotten, some of them right in our federal government’s backyard. Throughout the process, health officials have stressed that one problem Americans shouldn’t expect to face is cost. The vaccine’s on Uncle Sam, with no cost-sharing for the patient. But that doesn’t mean the America’s privatized and fractured healthcare system hasn’t interfered with getting vaccines into arms. Here’s a story of one such case—from a state with one of the highest rates of vaccination thus far.
Rachel* was understandably “elated” when she was able to schedule a vaccine appointment for her 65 year-old mom at a Walmart in Norwalk, Connecticut, on February 20th. Both her parents are grocery store workers, and both caught Covid-19 early in the pandemic; her mom, Mary*, took indefinite leave from her job at Whole Foods because of the risk, and Rachel and her husband are supporting her mom financially. (I’m using pseudonyms at Rachel’s request.) Rachel thinks her mom might be able to go back to work once she’s received both doses. Her stepdad was “incredibly sick for five weeks,” she told me. And her brother, who also works in a grocery store, has had Covid-19 twice—once early in the pandemic and then again in January, sparking fears that her parents could catch it twice, too.
But Rachel’s relief turned to anger and confusion when her mom’s appointment was canceled by Walmart the night before it was scheduled—seemingly because of an issue with billing.
Rachel told me that at around 7pm on February 19th, the pharmacy called Mary and asked for her insurance information. When the pharmacy ran her Medicare Advantage plan information, they told her they couldn’t vaccinate her the next day, because her address was still listed as being in New York state; Mary and her husband had moved to Connecticut a few weeks ago.
Rachel called Walmart herself the next day, thinking it was probably to do with proving her mom’s Connecticut residency and that they might still be able to get her in if they provided the right documents. But she was shocked when the pharmacy told her that it was actually a billing issue. Since Mary was still listed as living in New York state, the claim would be denied, they said. Rachel said she talked to a pharmacy associate and the pharmacist, and both said it was a billing issue. And that was that; no vaccine for Mary. Rachel later made a new appointment for her mom for March 5th, 13 days later. 13 more days in which Mary could be exposed to Covid-19.
The Medicare rate for vaccine administration is $16.94 for the first dose of a two-dose vaccine. That’s how much Walmart could expect to be reimbursed by the feds for administering this vaccine. Rachel said she feels bad for the pharmacy workers and doesn’t think it’s their fault, assuming that it’s a Walmart policy or that they fear they’ll be fired if they can’t run the claim. (Walmart’s corporate media relations team never got back to repeated requests for an explanation.)
Rachel looked into how her mom can update her Medicare address, and found she would have to change her address with the Social Security Administration and enroll in a new Medicare Advantage plan. Having Medicare Advantage is more like a regular insurance plan than classic Medicare—it has geographically limited provider networks, and is administered by private insurance providers (and is hugely profitable for them), so each time you move to a new county or state, you probably have to switch to a new plan to be able to see the doctor. Understandably, Rachel said there was no way for Mary to get this done between receiving the call at 7pm on Friday and the scheduled time of her appointment at 3pm on Saturday. She said her mom had only recently turned 65 and found the process of getting enrolled in Medicare “very complicated and intimidating.”
I called the Walmart location and spoke to the pharmacist, describing what happened and asking about their requirements for billing and eligibility. (I didn’t use Mary’s name specifically because I didn’t want to interfere with her ability to keep her later appointment, or give the pharmacy an excuse to cite HIPAA privacy regulations and hang up without talking to me.) The pharmacist made it sound like more of an eligibility issue as well as a billing issue, telling me: “If Medicare has them residing in another state, we can’t give it to them, because then the state of Connecticut is telling us, don’t vaccinate folks who doesn’t reside in Connecticut or work in Connecticut.” He also said: “if the Medicare has them residing in another state, that’s the proof that they don’t reside in Connecticut.”
I told him what Rachel had told me, that her mom had offered to bring a lease or utility bill as proof of residency, and that she had been told it was a billing issue. The pharmacist said “from our protocol and procedures that we follow, is whatever the insurance that’s presented to us, we have to bill them.” He said the pharmacy has had other similar cases, and the patients “contacted Medicare and were able to change it pretty quickly.” He was quite adamant that it was not difficult for Mary to simply update her Medicare address so that she could receive the vaccine.
I asked him if they could have just marked her down as uninsured and given her the vaccine anyway; he said no, because that would be untrue—would it, if she was now outside the Medicare Advantage plan’s service area?—and that the state requires uninsured patients to fill out a form attesting that they aren’t covered. I also asked what requirements the pharmacy has for proving Connecticut residency, and he said a picture ID with a Connecticut address. Rachel told me by email after this conversation that they didn’t mention a picture ID when she called: “I said we had multiple means of proving she was a resident of CT and they were insistent that that didn’t matter because the issue was the Medicare address/plan being NY and the fact that would result in a denied claim. When I called the pharmacy I thought the problem was proving residency, because of everything I had read about the vaccine being free and insurance not being barrier to access, but they were not focused on that in my conversation with them, they were focused on the billing issue.”
A Connecticut Department of Public Health Communications Adviser, David Dearborn, was unable to provide any clarity on any of these rules, but said the vaccine is provided regardless of insurance coverage status. I asked whether the state has any rules about how pharmacies must determine Connecticut residency and will update the web version of this post if I receive a response. A Connecticut Post article from January says there’s no official list of these documents, but that Department of Public Health spokeswoman Maura Fitzgerald told the paper “anything containing your home address should suffice -- for instance, a bill or piece of mail with your address printed by the sender or a library card.” Such documents are commonly accepted as evidence of residency for many government services in places around the country, like the DMV.
A spokesperson for the Center for Medicare and Medicaid Services told me that the Covid-19 vaccine is “covered and eligible for reimbursement regardless of the state in which it is administered […] Through the CDC COVID-19 Vaccination Program, the COVID-19 vaccine is free of charge for everyone.”
All organizations and providers participating in the CDC COVID-19 Vaccination Program:
· must administer COVID-19 Vaccine regardless of the vaccine recipient’s ability to pay COVID-19 Vaccine administration fees or coverage status
· may seek appropriate reimbursement from a program or plan that covers COVID-19 Vaccine administration fees for the vaccine recipient
· may not seek any reimbursement, including through balance billing, from the vaccine recipient
Yet the Medicare website tells patients: “Be sure to bring your red, white, and blue Medicare card so your health care provider or pharmacy can bill Medicare. You’ll need your Medicare card even if you’re enrolled in a Medicare Advantage Plan.” So is it free regardless of coverage, or not? What happens if you don’t? These are the sorts of questions the healthcare system just isn’t set up to consider—the awkward ones that highlight the gaping holes.
It appears that cases like Mary’s exist in a grey area. She should absolutely qualify for the vaccine based on her age and Connecticut residency; no doubt there, especially given that her husband was able to get the vaccine at a state-run site with no problems. But the question is whether any pharmacy is allowed to deny eligible people the vaccine based either on the suspicion that they don’t live in the state—even when, as Rachel said, the patient offers to bring proof of residency—or, worse, that they won’t be able to bill her insurance for that juicy $16.94. After contacting the Walmart location and its corporate office, CMS, and the Connecticut Department of Public Health, I still don’t know. All I know is Mary didn’t get vaccinated.
This gets to a much bigger problem with the American healthcare non-system—one of the biggest, in fact, a large part of the reason you can’t call it a system at all. When you pay for healthcare in the form of thousands of different insurance plans, government programs, and avenues of payment and reimbursement, you end up with situations like this. When you create a million different points of friction in the system, that’s a million different ways that things can go wrong. And things will go wrong. (It also raises the question of whether it was ever a good idea to have private pharmacies involved in the vaccine rollout at all; in nursing homes in some states, billing practices have slowed down the process of getting shots into arms. My answer to that question is “hell no.”)
Yet all the rules and guidelines assume, for some reason, that there aren’t going to be faults with a system that we already know creates gaps in coverage all the time, whether the fault is an insurance plan with an out-of-date address, a pharmacist taking a too-strict approach to eligibility and billing rules, or one of the world’s largest and Worst corporations with an incentive to give a person’s vaccine appointment away to someone who has insurance that will reimburse them, even if it is for $17. Don’t worry, the government says—it’s covered, whether you have insurance or not, whether your plan covers it or not. But bring your insurance card anyway. Why? Is the implication is that the pharmacy can decline to cover it if you don’t bring it? Isn’t it covered regardless? Yes. And, also, no, if you’re Mary and you go to the Norwalk Walmart.
This is the inevitable result of administering health insurance through many different payers, in different states, with networks and eligibility rules and endless forms to fill in. All of these things can be barriers to accessing care. Think of it like a flow chart that you have to reach the end of; it’s, if eligible under criteria AND forms are filled in correctly AND you haven’t moved AND you remember your card, etc, etc, you get care. Instead, it could be: If you are a human, you get care. If we had one universal program that covered everyone, paid providers directly without patient billing, and didn’t require a complicated administrative process every time you moved 30 minutes down the road—sure, it wouldn’t fix every problem in healthcare. But it would remove innumerable points of potential harm, disenfranchisement, and ultimately sickness. And a grocery store worker who’s too afraid to go to work could get her vaccine.
Rachel told me today she made a new appointment for her mom to get the vaccine—at a state-run site instead.