Insurance Circular Letter No. 10 (2023)

December 22, 2023

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 of Respiratory Syncytial Virus Immunizations

STATUTORY AND REGULATORY REFERENCES: N.Y. Insurance Law §§ 3216, 3221, and 4303 and 11 NYCRR 52 (Insurance Regulation 62)

I. Background and Purpose

Respiratory syncytial virus (“RSV”) is a respiratory virus that can be very harmful to young children, pregnant persons, and older adults. The U.S. Food and Drug Administration (“FDA”) approved RSV immunizations to protect adults aged 60 years and older, infants and young children, and pregnant persons beginning in May 2023. Following approval, the Advisory Committee on Immunization Practices (“ACIP”) of the Centers for Disease Control and Prevention (“CDC”) recommended the immunizations for adults aged 60 years and older, infants and young children, and pregnant persons at 32–36 weeks’ gestation to help protect against RSV.

The purpose of this circular letter is to remind insurers authorized to write accident and health insurance in this 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 (collectively “issuers”) of the requirements related to coverage of RSV immunizations under comprehensive health insurance policies and contracts. This circular letter does not apply to Child Health Plus, Essential Plan, and Medicaid managed care coverage.

II. Discussion

Insurance Law §§ 3216(i)(17), 3221(l)(8), and 4303(j)(2) 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 necessary immunizations by the Superintendent of Financial Services (“Superintendent”) in consultation with the Commissioner of Health (“Commissioner”). Insurance Circular Letter No. 13 (2006) provides that after consultation with the Commissioner of Health, the former Insurance Department determined that covered necessary immunizations under the law are those recommended by the ACIP. The Circular Letter further provides that “[t]he 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.” The ACIP recommended the RSV immunization on August 3, 2023 for infants and young children. Given the ACIP recommendation, issuers must cover the RSV immunization at no cost-sharing for infants and young children on and after August 3, 2023.

Insurance Law §§ 3216(i)(17)(E) and (F), 3221(l)(8)(E) and (G), and 4303(j)(3) and (4) further require individual, small group, and large group comprehensive health insurance policies and contracts, except for a grandfathered health plan¹, to provide coverage at no cost-sharing for preventive care and screenings that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Taskforce (“USPSTF”) and immunizations that have in effect a recommendation from the ACIP. Section 52.76(a)(2) of 11 NYCRR 52 (Insurance Regulation 62) requires an issuer to cover preventive care and screenings described in Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E), and 4303(j)(3) upon any policy or contract issuance or renewal that occurs six months after the date the recommendation or guideline is issued or revised. The ACIP recommended RSV immunizations on June 21, 2023 for adults aged 60 years and older and on September 22, 2023 for pregnant persons at 32–36 weeks’ gestation. While Insurance Regulation 62 requires issuers to cover the RSV immunizations at no cost-sharing for these adults upon policy issuance or renewal that occurs six months from the date of the recommendation, the Department strongly encourages issuers to provide immediate coverage because of the potential adverse impact to the health of these vulnerable persons.

III. Conclusion

Immunizations are essential to protect those persons at risk for RSV. Issuers are reminded of the requirements to cover RSV immunizations without cost-sharing under comprehensive health insurance policies and contracts. Issuers must cover RSV immunizations for infants and young children as of August 3, 2023. The Department also strongly encourages issuers to immediately cover RSV immunizations for adults aged 60 years and older and pregnant persons at 32–36 weeks’ gestation.

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

Very truly yours,

Lisette Johnson
Chief, Health Bureau

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), 4303(j)(4).