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By Suzanne Blake
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The U.S. Food and Drug Administration (FDA) has approved the updated COVID-19 vaccine for all adults age 65 and up, but Medicare often isn't covering the shot, forcing some seniors to pay out of pocket, according to a recent report from NBC News.
Newsweek reached out to the Centers for Medicare and Medicaid Services (CMS) for comment on Monday.
Why It Matters
Roughly 68 million Americans are enrolled in Medicare and rely on the government-run health insurance to cover medical checkups, treatments and procedures.
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However, a gap in coverage may force seniors to pay high costs out of pocket, significantly impacting their quality-of-life if they don't have sufficient funds on low-retirement savings accounts.
What To Know
One 74-year-old beneficiary, Allison Engel, was told by her CVS in Pasadena, California, that the cost of the shot would be $225 out of pocket, according to NBC News.
"They typed everything in, and handed me a rejection letter," she said. "They told me it wasn't in the Medicare system yet and I should come back in two weeks."
Instead of waiting, Engel decided to get the updated vaccine and paid out of pocket. She hopes Medicare reimburses her.
"The pharmacist tells my wife, 'We've had Medicare patients coming in all day, and everybody's upset because we can't give it,'" 78-year-old Brant Mittler of San Antonio, Texas, told NBC News.
Mittler, however, said he and his wife got their shots after the pharmacist said Medicare had updated the system there.
Patient experiences like this arrive in stark contrast to Department of Health and Human Services (HHS) Secretary Robert F. Kennedy Jr.'s statements when he told a Senate committee on Thursday that most Americans will be able to get the COVID-19 vaccine from their pharmacy for free.
"Anybody can get the booster," Kennedy Jr. said previously. "Most Americans will be able to get it from their pharmacy."
The coverage gap may be related to the Centers for Disease Control and Prevention's (CDC) Advisory Committee on Immunization Practices' meeting having not occurred yet. While it usually takes place earlier in the year, the meeting is set to take place on September 18.
However, typically Medicare is authorized to cover vaccines once the FDA approves it.
"A few payers are still updating their systems and may not yet be set up to cover the updated Covid-19 vaccines," CVS spokesperson Amy Thibault told NBC News. "If this happens, our pharmacy teams can help patients schedule an appointment for a later date."
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What People Are Saying
Arthur Caplan, the head of the division of medical ethics at NYU Langone Medical Center in New York City, told NBC News: "Medicare should be covering the shots, but it isn't clearing people. So again, this just stirs up uncertainty about, 'OK, am I eligible? Am I in the risk group?' People still aren't sure."
Kevin Thompson, the CEO of 9i Capital Group and the host of the 9innings podcast, told Newsweek: "Some that cannot afford the shot will go without forcing them to roll the dice on exposure. Right now, the new COVID shot is only approved for those 65 and older or folks with serious health risks. Everyone else is in limbo, and until the CDC weighs in, we don't know if access will actually open up."
Alex Beene, a financial literacy instructor for the University of Tennessee at Martin, told Newsweek: "Some may view this development as an expected one. As the pandemic is increasingly in the rear view mirror, many of the COVID era-policies pertaining to healthcare coverage have slowly fallen to the wayside. However, the reality is COVID outbreaks are still prevalent, and those more likely to experience sizable setbacks from the virus still prefer to receive additional protection."
What Happens Next?
If Medicare continues to not cover the new COVID vaccine, seniors could face increased health risks, Beene said.
"The elimination of gap coverage could lead to fewer getting the shot and subsequently more health risks," he said. "The sticker shock is undoubtedly going to lead to some saying financially it just isn't worth it, and that's very unfortunate."
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