Section 2001.8 Coverage of Preventive Health Services

TITLE 50: INSURANCE

CHAPTER I: DEPARTMENT OF INSURANCE

SUBCHAPTER z: ACCIDENT AND HEALTH INSURANCE

PART 2001 CONSTRUCTION AND FILING OF ACCIDENT AND HEALTH INSURANCE POLICY FORMS

SECTION 2001.8 COVERAGE OF PREVENTIVE HEALTH SERVICES

Section 2001.8  Coverage of Preventive

Health Services

a)         A

group health plan, or a health insurance issuer offering group or individual

health insurance coverage, must cover preventive services without cost-sharing

as described in Sections 356z.62 and 356z.77 of the Code.

1)

For

the purposes of Section 356z.62(a)(2) of the Code, a plan or issuer must cover

an immunization if it is for routine use in children, adolescents, or adults

and it has a recommendation in effect from

the Advisory Committee

on Immunization Practices (ACIP) of the Centers for Disease Control and

Prevention (CDC)

with respect to the individual involved

.

2)         A

limited health care plan or a policy of accident and health insurance that is

designed to coordinate with other group or individual health insurance coverage

or a group health plan to cover preventive services must cover the preventive

services and related administration without cost-sharing to the same extent as

the coordinating plan or policy.

3)

A

group health plan or health insurance issuer offering group or individual

health insurance coverage must ensure that neither it nor any utilization

review program conducted for its plan or coverage renders an adverse

determination about the medical necessity of a preventive service or related

administration contrary to the recommendations and guidance applicable to the

plan or coverage under subsection (a), as established by Sections 356z.62 and

356z.77 of the Code. Nothing in this subsection (a)(3) prevents a plan, issuer,

or utilization review program from rendering an adverse determination when a

preventive service is contraindicated for the covered individual.

4)         The

examples at 45 CFR 147.130(a)(2) (Nov

mendations and guidance applicable to the

plan or coverage under subsection (a), as established by Sections 356z.62 and

356z.77 of the Code. Nothing in this subsection (a)(3) prevents a plan, issuer,

or utilization review program from rendering an adverse determination when a

preventive service is contraindicated for the covered individual.

4)         The

examples at 45 CFR 147.130(a)(2) (Nov. 6, 2020) (no later editions or

amendments) illustrate the requirements of Section 356z.62(c) of the Code.

b)

Specific Requirements for Immunization Coverage

1)

An

ACIP recommendation is considered in effect after it has been adopted by the

Director of CDC.  An immunization is considered to be "for routine use"

if it is listed on the Immunization Schedules of the CDC.

2)

State

Guidelines are considered "in effect" when the Department of Public

Health publishes them under Section 1.2(d) of the Communicable Disease

Prevention Act or the Immunization Advisory Committee republishes them after an

override vote under Section 8.4(e) of the Department of Public Health Act.

3)

A

group health plan or a health insurance issuer offering group or individual

health insurance coverage must implement Section 356z.77 of the Code consistent

with the requirements of Section 356z.62(c) through (g), (i), and (j) of the

Code.

c)

Shared

clinical decision-making

When a recommendation

or guideline under Sections 356z.62 or 356z.77 of the Code does not require a

specific set of considerations or decision points in the shared clinical decision-making

process, a group health plan or a health insurance issuer offering group or

individual health insurance coverage, or its designee utilization review

program, must not deny or exclude coverage based on any of the following:

1)         The

health care provider or covered individual did not follow a specific set of

considerations or decision points that the plan, issuer, or utilization review

program prescribed for the shared clinical decision-making process

ng group or

individual health insurance coverage, or its designee utilization review

program, must not deny or exclude coverage based on any of the following:

1)         The

health care provider or covered individual did not follow a specific set of

considerations or decision points that the plan, issuer, or utilization review

program prescribed for the shared clinical decision-making process.

2)

The health care provider relied on a patient questionnaire or patient

disclosure form given to the covered individual before the administration of

the immunization to share or receive information relevant to the provider's

shared clinical decision-making process with the covered individual.

3)         To the

maximum extent allowed by the standards of practice in the State where the

covered individual received the preventive service, the health care provider

with whom the covered individual directly engaged in shared clinical

decision-making was not the covered individual's primary care physician or

attending physician. Nothing in this subsection (c)(3) prohibits a health

maintenance organization health care plan from applying referral requirements

it generally applies to a preventive service.

d)         Applicability

1)

If differing State and federal recommendations or guidelines apply to

the same preventive service, coverage must be provided consistent with the

recommendation or guideline that provides the greater scope of coverage for the

covered individual.

2)

Nothing

in this Section may be construed to extend the requirements of Section 356z.62

of the Code to grandfathered health plans.

3)

The provisions of this Section that implement coverage for

immunizations under Section 356z.77 of the Code apply to grandfathered health

plans. This includes subsections (a)(2), (a)(3), (a)(4), (b), (c), and (d)(1).