Circular Letter No. 13 (2006)

May 10, 2006


All Insurers Licensed to Write Accident and Health Insurance in New York State ("Commercial Insurers"), Article 43 Corporations and Health Maintenance Organizations (HMOs).


Coverage for Preventive and Primary Care Services.

STATUTORY REFERENCE:  New York Insurance Law Sections 3216(i)(17), 3221(l)(8) and 4303(j).

Chapter 728 of the Laws of 1993 requires that every policy providing medical, major medical or similar comprehensive type coverage provide coverage for preventive and primary care services for dependent children to age nineteen.

The legislation sets forth the preventive and primary care services that must be covered, including well child visits. The schedule of well child visits, as well as the services to be provided at such visits, are to be in accordance with the prevailing clinical standards of a national association of pediatric physicians, as designated by the New York State Commissioner of Health. In addition, the legislation requires coverage for necessary immunizations as determined by the Insurance Department in consultation with the Commissioner of Health, including those immunizations specifically set forth in the law.

By Circular Letter No.3 (1994), the Insurance Department advised commercial insurers, Article 43 corporations, and HMOs that the standards of the American Academy of Pediatrics (AAP) had been designated by the Commissioner of Health as the clinical standards to be utilized in determining the schedule of well child visits and the services to be provided at such visits. In addition, at that time, the Department advised that covered necessary immunizations consisted of those immunizations specifically set forth in the law. Subsequently, after consultation with the Commissioner of Health, the Insurance Department issued Circular Letter No. 34 (2000) to modify the list of covered necessary immunizations to include any immunization recommended by the AAP.

The purpose of this Circular Letter is to further modify Circular Letter No. 3 (1994) insofar as it relates to those necessary immunizations for which coverage must be provided pursuant to Chapter 728 of the Laws of 1993 and to withdraw Circular Letter No. 34 (2000), which is superseded by this Circular Letter. Recent experiences with coverage of the conjugate meningococcal vaccine Menactra or MCV4 necessitated that the Department review the position that it took in its prior Circular Letters. Specifically, the Commissioner of Health has advised that tying insurance coverage of a new immunization to recommendation by the AAP may result in a delay in coverage for some children in New York State. The Commissioner advises that recommendations regarding the use of new vaccines are usually made first by the Advisory Committee on Immunization Practices (ACIP). The AAP typically follows later with the same recommendation. The Vaccines for Children Program, which provides immunizations for children up to age 19 who are covered by Medicaid or Medicaid Managed Care or are uninsured, Native American or underinsured, covers all vaccines recommended by the ACIP. The result is that children in New York State covered by the Vaccines for Children Program might have access to covered vaccines more quickly than children covered by private health insurance.

For that reason, and based upon the recommendation of the Commissioner of Health, the Department has determined that covered necessary immunizations under the law are those recommended by the ACIP. The Department expects that, should the ACIP amend its recommended childhood immunization schedule subsequent to issuance to this Circular Letter, insurers, Article 43 corporations and HMOs will take the necessary steps to provide coverage in accordance with the ACIP revised schedule, effective as of the date of the change, without further communication from this Department.

Please direct any questions concerning this Circular Letter to:

Deborah A. Kozemko, J.D.
Supervising Insurance Attorney
New York State Insurance Department
One Commerce Plaza
Albany, New York 12257

Or by e-mail to Deborah A. Kozemko

Very truly yours,

Charles Rapacciuolo
Assistant Deputy Superintendent and Chief
Health Bureau