Insurance Circular Letter No. 12

August 31, 2022

TO:

All Insurers Authorized to Write Accident and Health Insurance in New York State, Article 43 Corporations, Health Maintenance Organizations, Student Health Plans Certified Pursuant to Insurance Law § 1124, Municipal Cooperative Health Benefit Plans, and Prepaid Health Services Plans

RE:

Coverage for Immunization Against, Testing for, and Diagnosis of the Monkeypox Virus

STATUTORY REFERENCES: N.Y. Insurance Law §§ 3216, 3217-h, 3217-i, 3221, 4303, 4306-g, 4306-h, and 4328; N.Y. Public Health Law 4406-g; Executive Order No. 20; and Executive Order No. 20.1

I. Background and Purpose

Due to the ongoing spread of the monkeypox virus and the significant risk that this virus poses, the monkeypox virus has been declared an Imminent Threat to Public Health by the New York State Commissioner of Health as of July 28, 2022. Governor Hochul issued Executive Order No. 20 on July 29, 2022, which declared a State disaster emergency in order to combat the spread of the monkeypox virus. Governor Hochul subsequently issued Executive Order No. 20.1 (“EO 20.1”) on August 28, 2022, to ensure that health insurance coverage requirements and copayments, coinsurance, and annual deductibles (“cost-sharing”) do not serve as a barrier to testing for, diagnosis of, and immunization against monkeypox.

The purpose of this circular letter is to provide guidance to insurers authorized to write accident and health insurance in this state, Article 43 corporations, health maintenance organizations, student health plans certified pursuant to New York Insurance Law § 1124, municipal cooperative health benefit plans, and prepaid health services plans[1] (collectively, “issuers”) related to coverage of monkeypox virus testing, diagnosis, and immunization under comprehensive health insurance policies and contracts.

II. Discussion

A. Monkeypox Virus Immunization

Insurance Law §§ 3216(i)(17)(B)(ii) and (iii), 3221(l)(8)(B)(ii) and (iii), and 4303(j)(2)(B) and (C) require individual, small group, and large group comprehensive health insurance policies and contracts to cover immunizations, at no cost-sharing, for children through the attainment of 19 years-of-age if determined to be a necessary immunization by the Superintendent of Financial Services in consultation with the Commissioner of Health. Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E), and 4303(j)(3) require individual, small group, and large group comprehensive health insurance policies and contracts, except for a grandfathered health plan,[2] to provide coverage at no cost-sharing for immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices (“ACIP”) of the Centers for Disease Control and Prevention (“CDC”). Governor Hochul issued EO 20.1 to ensure that issuers cover the monkeypox vaccine and vaccine administration for all persons who are eligible for the vaccine, including persons covered under grandfathered plans, regardless of whether they fall within the specific ACIP recommendation. EO 20.1 temporarily modifies Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E), and 4303(j)(3) to require issuers to cover the monkeypox virus immunization and the administration thereof, without any cost-sharing when provided in-network or out-of-network.

B. Monkeypox Virus Testing and Diagnosis

Laboratory tests and ambulatory patient services, including office visits and urgent care, are essential health benefits (“EHB”), and as such, must be covered under individual and small group comprehensive health insurance policies and contracts pursuant to Insurance Law §§ 3217-i(a)(1), 3221(h), 4303(ll), 4306-h(a)(1), and 4328(b)(1). Insurance Law §§ 3221(l)(3) and 4303(e) and (f) also require issuers of large group comprehensive health insurance policies and contracts to make available coverage for ambulatory care, including laboratory tests, and such services are typically covered in the base policy or contract. EO 20.1 temporarily modifies Insurance Law §§ 3221(h) and (l)(3), 4303(e)(1), (f)(1), and (ll), and 4328(b)(1) to waive cost-sharing for: (1) in-network laboratory testing to diagnose the monkeypox virus; and (2) visits to diagnose the monkeypox virus at the following locations: an in-network provider’s office, an in-network urgent care center, any other in-network outpatient provider setting able to diagnose monkeypox, or an emergency department of a hospital. An issuer shall provide written notification to its in-network providers that they shall not collect any deductible, copayment, or coinsurance. However, cost-sharing may be imposed for any follow-up care or treatment for the monkeypox virus, including an inpatient hospital admission, in accordance with the applicable policy or contract, as permitted by law. Additionally, a deductible may be applied for high deductible health plans if otherwise required by law.[3]

Issuers are also reminded that Insurance Law §§ 3217-h and 4306-g and Public Health Law § 4406-g prohibit the exclusion of a service that is otherwise covered under a comprehensive health insurance policy or contract because the service is delivered via telehealth, including telehealth services performed for the purpose of diagnosing the monkeypox virus. Chapter 57 of the Laws of 2022 amended the above sections to require that services delivered via telehealth be reimbursed on the same basis, at the same rate, and to the same extent that such services are reimbursed as when delivered in person. Chapter 57 of the Laws of 2022 also requires issuers to maintain a network adequate to meet the telehealth needs of insureds for services covered under the health insurance policy or contract, when medically appropriate.

C. Keep Consumers Informed.

Access to accurate information and avoiding misinformation are critical. Therefore, issuers should devote resources to informing insureds of available benefits and quickly respond to insured inquiries. Issuers should make all necessary and useful information available on their websites and staff their nurse help-lines accordingly.

III. Conclusion

In order to stop the spread of monkeypox and reduce the significant risk that the monkeypox virus poses to human health, it is imperative that health insurance coverage requirements and cost-sharing do not serve as a barrier to testing, diagnosing, and immunizing New Yorkers. Issuers must provide coverage of monkeypox virus testing, diagnosis, and immunizations in accordance with EO 20.1 and this circular letter.

Please direct any questions regarding this circular letter by email to [email protected].

Very truly yours,

 

Lisette Johnson
Chief, Health Bureau

[1] The reference to prepaid health services plans only includes commercial insurance coverage written by such plans.

[2] A “grandfathered health plan” means coverage provided by an issuer in which an individual was enrolled on March 23, 2010, for as long as the coverage maintains grandfathered status in accordance with 42 U.S.C § 18011(e). Ins. Law §§ 3216(i)(17)(F), 3221(l)(8)(G), and 4303(j)(4).

[3] A “high deductible health plan” means a health plan as defined by Internal Revenue Code § 223(c)(2).