On Saturday, Keilani Lime went to a local pharmacy to pick up some medication.
A Ferrisburgh resident, Lime has Ehlers-Danlos syndrome, a genetic condition that affects the body’s connective tissue, and Lyme disease. She takes multiple drugs to prevent muscle spasms and to ward off Lyme disease symptoms.
Lime, who has health insurance through Medicaid, expected the drugs to be fully covered. Instead, she said, pharmacy staff told her that, because a cyberattack had disabled the claims processing system, she would have to pay completely out of pocket — roughly $50. She decided to pay.
“I need these medications,” she said. “Otherwise I end up in the emergency room.”
After a cyberattack disabled a key claims processing system nationwide last week, some Vermont customers and pharmacies have struggled to access or dispense medications — stoking fears about a further prolonged outage.
Change Healthcare, a pharmacy management company and part of health care giant UnitedHealthcare, announced last Wednesday that it had been struck by a cyberattack. The incident disabled programs that pharmacies across the country use to process Medicaid claims.
Vermont contracts with Change Healthcare to run the state’s Medicaid prescription claims program. Roughly 200,000 Vermont residents — nearly a third of the state’s population — receive health insurance through Medicaid.
The system is expected to remain down at least through the end of the week, according to Alex McCracken, a spokesperson for the Department of Vermont Health Access, which runs the state’s Medicaid program. When it does resume functioning, it’s expected to do so incrementally, he said.
Already the outage has disrupted some Vermonters’ medical treatment, though it’s unclear how widespread the impact has been in the state.
Sherri, a Vermont resident who agreed to an interview on the condition that her last name be withheld for privacy reasons, told VTDigger that she had a medical procedure postponed indefinitely because of the incident.
Sherri has an autoimmune disorder that is treated in part by injections of antibodies, a procedure called intravenous immunoglobulin. Sherri, who is insured by both Medicaid and Blue Cross Blue Shield, said that she was hoping to receive the treatment at home this week.
But after the cyberattack, Sherri’s provider postponed the procedure indefinitely.
“They’ve still been unable to process anything related to this claim and stuff,” she said. “And since Monday, they don’t have a date.”
Without that procedure, Sherri said, her autoimmune condition could worsen, potentially causing damage to her nervous system and making her more susceptible to illnesses.
‘Very seriously’
McCracken, the Department of Vermont Health Access spokesperson, said that he was unaware of any procedures being canceled as a result of the outage.
But he said that state officials are aware of a handful of situations in which patients like Lime were billed for medications that should be fully covered by insurance.
“Federal law prohibits charging Medicaid members for medications that the state would cover,” McCracken said. “We want to reinforce again that no member should ever be unable to access their medication at a pharmacy in this outage.”
The state is taking such incidents “very seriously,” McCracken said. “We are reaching out directly to the pharmacies involved in ensuring that they are complying with the guidance received from the state.”
‘A difficult position’
Meanwhile, on the other side of the counter, the outage has placed pharmacists in a difficult position.
Pharmacies are unable to submit claims — and receive payment — for prescriptions for Medicaid-covered patients. That has left some small pharmacies anxious about cash flow.
Lynne Vezina, the owner of Burlington’s Vermont Family Pharmacy, said she was “greatly concerned” about the prospect of running out of cash.
“We have to pay for our drugs every two weeks,” she said. “So I’ve already gone a whole week and now I’ll go another week — I mean, I don’t know — and we’re not getting the money from Medicaid.”
The Vermont Department of Health Access announced Wednesday that it had issued payments to pharmacies equal to the amount of money they receive from Medicaid claims in an average week.
But, Vezina noted, it was still unclear how long the outage would last — and claims can vary significantly week to week, she said.
“If you have a really expensive week where you’re giving out a lot of insulin, or a lot of really expensive medications, it’s not going to cover it,” she said.
The cyberattack has also made it difficult to tell whether Medicaid will cover a certain drug, small pharmacists say. So when patients come in with a prescription for medication, it’s not always clear whether pharmacists will be able to be reimbursed for it, they said.
“We don’t have any ideas whether those prescriptions are going to be covered, if there’s a prior approval needed for them,” said Jason Hochberg, a co-owner of Smilin’ Steve Pharmacies, which operates six locations in southern Vermont.
Hochberg said that pharmacies have not received “a whole lot of guidance” from the state’s Medicaid program.
“They haven’t come out and guaranteed that we’ll be reimbursed wholly for us lending medications out,” Hochberg said, referring to the practice of dispensing drugs without knowing their coverage status. “So it’s putting pharmacies in a difficult position.”
The Department of Vermont Health Access told pharmacies in an email Wednesday that the state has stood up a phone and online system to determine customers’ eligibility for drugs covered by Medicaid.
But McCracken, the department spokesperson, said that the state was aware of pharmacists’ fears.
“We hear this concern,” McCracken said. “We’re working with pharmacies very closely to make sure that they have what they need.”
Meanwhile, Lime, the Ferrisburgh resident, said that she is working on a letter to lawmakers about the issue. Lime is the vice chair of the Vermont Democratic Disability Caucus, which advocates for policies focused on disability rights.
She recently received notice that another drug, an antibiotic, was ready for pickup at her pharmacy. The pharmacy told her that the medication would cost $52.59, she said.
“I don’t have money to pay for this,” she said. “It’s pretty terrifying.”
