Unraveling the Mysteries Surrounding the Latest COVID-19 Vaccine and Medicare: Essential Information Explained
The ongoing regulatory patchwork surrounding the COVID-19 vaccine has led to confusion and barriers for Medicare beneficiaries. The Advisory Committee on Immunization Practices (ACIP) has yet to vote on updated recommendations for the vaccine, leaving some pharmacies to hold off on administering it or only offering it with a doctor's prescription.
The U.S. Food and Drug Administration (FDA) has approved the vaccine for specific groups, including those 65 and older and those with certain underlying health conditions that increase their risk of severe COVID-19. However, FDA approval alone doesn't guarantee access to the vaccine in 18 states and Washington, D.C., where pharmacists can only administer a vaccine if it has also been recommended by the ACIP.
The CDC's failure to formally adopt the FDA's recommendations is causing further complications. In these 18 states and Washington, D.C., the states where this regulation applies are: Colorado, Connecticut, Georgia, Iowa, Kentucky, Maine, Maryland, Massachusetts, Montana, Nevada, New Jersey, New Mexico, North Carolina, Oregon, Pennsylvania, South Carolina, Virginia, and West Virginia, pharmacists are allowed to administer COVID-19 vaccines only if recommended by the ACIP.
This transition of the vaccine to the commercial market after Secretary Kennedy declared the public health emergency over has led to administrative hurdles and confusion about new billing codes, causing some pharmacies to deny coverage. If you encounter issues getting your vaccine, contact Medicare directly at 1-800-MEDICARE for help.
It's worth calling your local pharmacy before you head out due to confusion over FDA vs CDC approval and the need to update computer systems to properly process vaccine authorizations at pharmacy counters. If a Medicare Part B plan covers the COVID-19 vaccine, then the Medicare Advantage plan also has to cover it. However, if you have a Medicare Advantage plan, you may need to go to a pharmacy or provider that is in your plan's network.
If you have Medicare and meet the FDA's criteria, a denial for a covered vaccine is improper. Some Medicare beneficiaries who were denied coverage for the COVID-19 vaccine were told to pay out of pocket, with costs exceeding $200. If you find yourself in this situation, don't hesitate to contact Medicare for assistance.
In June, all 17 members of the ACIP were removed by HHS Secretary Kennedy, citing the need to reestablish public confidence in vaccine science. Despite this, the ACIP did not take a vote on COVID-19 vaccine recommendations during their June 25 meeting. They did, however, approve recommendations for the RSV and seasonal influenza vaccines.
Remember, Medicare Part B covers the COVID-19 vaccine, including all updated versions, at no cost to beneficiaries. If you have any questions or concerns about your coverage, reach out to Medicare for guidance. Stay informed, stay safe, and get vaccinated.
