Circular Letter No. 34 (2000)

October 24, 2000

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 applies to all policies and contracts issued, renewed, modified, altered or amended on or after such date.

The legislation sets forth the preventive and primary care services which 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 insurers, Article 43 corporations and HMOs that the standards of the American Academy of Pediatrics 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, the Department advised that covered necessary immunizations consisted of those immunizations specifically set forth in the law.

The purpose of this Circular Letter is to 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.

After consultation with the Commissioner of Health, the Department has determined that covered necessary immunizations are those recommended by the American Academy of Pediatrics which, to date, include adequate dosages of vaccines against diphtheria, pertussis, tetanus, polio, measles, mumps, rubella, Haemophilus influenzae type B, hepatitis B, varicella, hepatitis A (in selected geographic areas) and pneumococcal conjugate vaccine (Prevnar).

It is this Department’s expectation that should the American Academy of Pediatrics amend its recommended childhood immunization schedule subsequent to issuance of this Circular Letter, insurers, Article 43 corporations and HMOs will take the necessary steps to provide coverage in accordance with the American Academy of Pediatrics 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
Associate Insurance Attorney
New York State Insurance Department
Agency Building 1
Empire State Plaza
Albany, New York 12257

or by e-mail to: [email protected]