Title: Insurance Coverage Gap Leaves Medicare Enrollees and Private Insured Individuals Paying Out-of-Pocket for R.S.V. Vaccine
Subtitle: Inconsistent policies create barriers to access, leaving vulnerable populations unprotected
Byline: [Author Name]
[City, State] – Lucien Dhooge, a 63-year-old law and ethics instructor at the University of Washington Tacoma, took proactive measures to protect himself against the flu and respiratory syncytial virus (R.S.V.) this year. However, his attempt to receive the new R.S.V. vaccine was met with disappointment when his insurance provider, Anthem Blue Cross Blue Shield, refused to cover the cost. Dhooge was faced with an out-of-pocket expense of approximately $330, prompting him to reconsider his decision.
The Food and Drug Administration’s approval of two R.S.V. vaccines this year marked a significant breakthrough for adults aged 60 and above. R.S.V. claims the lives of up to 10,000 individuals over the age of 65 in the United States annually, with many more hospitalized. Pfizer and GSK have manufactured these vaccines, which have shown over 80% effectiveness in preventing lower respiratory symptoms associated with R.S.V.
Unfortunately, some insurance plans, including Medicare Part B, do not cover the cost of the R.S.V. vaccine. Amanda Jaffe, a 69-year-old Medicare enrollee, discovered she would have to pay over $300 for the vaccine when she visited her local pharmacy in Helena, Montana. Faced with the steep price, she decided against receiving the shot. This scenario is particularly concerning as Medicare Part D, which covers prescription drugs, is the designated insurance plan for vaccines like R.S.V. and shingles.
Richard Hughes IV, a vaccine-law expert, emphasizes the impact of fragmented policies on vaccine accessibility. He argues that all vaccines, including R.S.V., should be accessible in all healthcare settings. The Centers for Medicare & Medicaid Services clarifies that individuals with Medicare Part D should have access to the R.S.V. vaccine free of charge. If individuals encounter any resistance or misinformation, they are urged to contact 1-800-MEDICARE for assistance.
For those with private insurance, such as Lucien Dhooge, the coverage situation remains uncertain. While the Affordable Care Act mandates coverage for preventive care, including vaccines recommended by the Advisory Committee on Immunization Practices (A.C.I.P.), there is flexibility when it comes to R.S.V. vaccine coverage. The final decision lies with individuals and their healthcare providers, leading some insurers to exploit this as a loophole for non-coverage.
Another hindrance to insurance coverage for the R.S.V. vaccine is its exclusion from the C.D.C.’s annual vaccine schedule for adults. Blue Cross Blue Shield, in response to inquiries, stated that until R.S.V. appears on the immunization schedule, it is up to individual B.C.B.S. plans to decide whether to cover the vaccine or not.
However, some private insurers are already providing coverage for the R.S.V. vaccine. Teresa Schulteis, a 65-year-old Medicare Advantage plan holder through United Healthcare, had no trouble receiving the vaccine at Walgreens, free of charge.
As insurance coverage policies vary, experts recommend reaching out to healthcare providers and insurers to determine whether the R.S.V. vaccine is covered before scheduling an appointment. The inconsistent coverage highlights the need for better coordination and policies to ensure affordable access for all individuals, especially vulnerable populations.
In the meantime, individuals like Lucien Dhooge and Amanda Jaffe find themselves caught in a coverage gap, unable to afford the potentially lifesaving R.S.V. vaccine. As public demand for accessibility grows, policymakers and insurers must act swiftly to bridge this gap and protect the health of at-risk individuals nationwide.
Sources:
– The New York Times