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The National Immunization Program Presents: Understanding and Strengthening State Insurance Laws Providing Immunization Coverage NET CONFERENCE: July 9, 2004 12 1 pm Presented by Sara Rosenbaum, J.D. Learn about: A new project providing technical assistance to state policy makers, program administrators, and others seeking improvement in immunization coverage and performance standards. Available technical assistance tools including: -- model health insurance legislation with customized model laws for all states, -- hands-on technical assistance in the development of contractual performance standards related to immunization coverage and practice. Review a draft of a proposed model law. Discover where your state stands. The Epidemiology of U.S. Immunization Law Slide 2 33 jurisdictions (32 states + DC) maintain an immunization coverage law SLIDE 1 GWU/SPHHS/CHSRP Analysis of State Immunization Laws, Winter 2003 WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS RI CT VT MA NH AK HI DE MD DC Law (AR,CA,CO,CT,DE,DC,FL,GA,HI,IL,KS,LA,MD,MA,MI,MN,MS,MO,MT,NE,NJ,NM,NY,NC,ND,OH, OK,PA,RI,TX,VA,W.VA,WI) No Law (AL,AK,AZ, HI, IN, IA,KY, ME, NV, NH, O R,SC, SD, TN, UT,VT,WA,WY) Slide 3 States with immunization laws and/or universal programs (n = 51) SLIDE 2 GWU/SPHHS/CHSRP Analysis of State Immunization Laws, Winter 2003 WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS RI CT VT MA NH AK HI DE MD DC Law Only (AR, CA, CO, DE, DC, FL, GA, IL, KS, LA, MD, MI, MN, MS, MO, MT, NE, NJ, NY, OH, OK, PA, TX, VA, WVA, WI) Law and Universal (MA, NM, NC, RI) Law and Universal Select (CT, HI, ND) Universal or Universal Select Only (AK, ID, ME, NV, NH, SD, VT, WA, WY) No Law and No Universal or Universal Select (AL, AZ, IN, IA, KY, OR, SC, TN, UT) Slide 4 State immunization laws that incorporate the ACIP coverage standard for some or all children under 18 (n = 6) SLIDE 3 WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS NJ RI CT VT MA NH AK HI DE MD DC California, Hawaii, Maryland, Montana, New Jersey, and Pennsylvania laws require immunization coverage based on the ACIP recommendations. GWU/SPHHS/CHSRP Analysis of State Immunization Laws, Winter 2003 Slide 5 Costsharing provisions in state insurance laws (n = 33) SLIDE 4 WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS NJ RI CT VT MA NH AK HI DE MD DC PROHIBITS COSTSHARING (AR, HI, KS, MN, MO, MS, NY, NC, OK, TX, VA, WI, WV) SILENT REGARDING ALL COSTSHARING (CA, CT, DE, DC, MA, MI) PERMITS ALL COSTSHARING (IL, LA, NM, OH) PERMITS COPAYMENTS/PROHIBITS DEDUCTIBLE (CO, NE, PA) SILENT ON COPAYMENTS/PROHIBITS DEDUCTIBLE (FL, GA, MD, MT, NJ) PERMITS COPAYMENTS/SILENT RE DEDUCTIBLE (ND, RI) GWU/SPHHS/CHSRP Analysis of State Immunization Laws, Winter 2003 Slide 6 Comprehensive Immunization Laws: Composite Range (Pediatric Coverage Only) SLIDE 5 ELEMENTS OF COMPOSITE STATUTE COMPOSITE 1 (n = 0) COMPOSITE 2 (n = 1) COMPOSITE 3 (n = 2) COMPOSITE 4 (n = 15) Age groups covered by law Birth-18Birth-18, or any subgroup Birth-18, or any subgroup Birth-18, or any subgroup Standard of coverage ACIP ACIP, or other standard Deductibles and cost sharing Prohibited Prohibited, or deductibles prohibited but copayments allowed Prohibited, or deductibles prohibited but copayments allowed Slide 7 Composite 2: More limited age standards (n = 1) SLIDE 6 WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS NJ RI CT VT MA NH AK HI DE MD DC Hawaiis law requires coverage for children up to age six, under ACIP standards, and prohibits copayments and deductibles. GWU/SPHHS/CHSRP Analysis of State Immunization Laws, Winter 2003 Slide 8 Composite 3: More limited age and costsharing standards (n = 2) SLIDE 7 WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS NJ RI CT VT MA NH AK HI DE MD DC Hawaiis law requires coverage for children up to age six, under ACIP standards, and prohibits copayments and deductibles. Pennsylvanias law requires coverage for children, under ACIP standards, and permits copayments. GWU/SPHHS/CHSRP Analysis of State Immunization Laws, Winter 2003 Slide 9 Composite 4: More limited age standards, copayment, and coverage standards (n = 15) SLIDE 8 WA OR ID MT ND WY SD MN WI MI ILIN OH PA NY ME CA NV UT CO NE KS IA MO KY WV VA NC TX NM AZ OK AR LA TN SC GA FL AL MS NJ RI CT VT MA NH AK HI DE MD DC HIs law requires coverage for children up to age six, under ACIP standards, and prohibits copayments and deductibles. PAs law requires coverage for children, under ACIP standards, and permits copayments. AR, KS, MN, MS, MO, NE, NY, NC, OK, TX, VA, WV, WIs laws requires coverage for children, according to any standard, either permits or prohibits copayments, prohibits deductibles. GWU/SPHHS/CHSRP Analysis of State Immunization Laws, Winter 2003 Slide 10 Accessing the Project Website SLIDE 9 1.www.gwhealthpolicy.org/immunizationwww.gwhealthpolicy.org/immunization -- Access the Introduction Page to the initiative 2.State Statute Report Link -- Access the Model Statute and the U.S. Map 3.Map Link to Map of State Statutes & Recommended Language -- Access the Map of U.S., click on any state to find Tables 4.From Map page go to the Tab labeled Reports -- Access reports of state laws and Medicaid. Slide 11 SECTION 1. DEFINTIONS For the purposes of this act: beneficiary means a person or persons specified by a policyholder as eligible to receive benefits under the insurance contract or policy. co-insurance means the percentage of a providers negotiated fee the enrollee must pay for care, up to a yearly defined maximum. co-payment means a cost-sharing arrangement in which a beneficiary pays a specified charge for a specified service. The beneficiary is usually responsible for payment at the time the service is rendered. cost-sharing means a method of reimbursement for health care services that holds the patient responsible for a portion or percentage of the charge with an attending strategy to serve as a means of reducing utilization. covered benefit means a written health care benefit document that outlines the benefit package to be provided to either individual beneficiaries or a purchasing group or employer, with a corresponding sum for each service specified for beneficiaries by an insurer in the state. deductible means a specific dollar amount you must pay before the benefit plan begins paying for covered services. dependent means an enrolled health plan member who has coverage tied to that of the sponsor; may be a spouse or an unmarried child, or a stepchild or legally adopted child of either the beneficiary or the beneficiarys spouse, whose primary domicile is with the beneficiary, except for the other arrangements as approved by the plan; often dependent children status is also delineated by those under the age of 18, or children attending college full-time under a specified age. ''health benefits plan'' means a group or individual insurance policy or contract, medical or hospital service agreement, membership or subscription contract, or similar group or individual arrangements provided by a carrier for the purpose of providing, paying for, or reimbursing expenses for health services; network means a health benefit plan that operates through a series of contracts with multiple physician groups and hospitals to provide a defined group of providers from which a health plan member may choose from to receive covered health services. Services obtained from providers included in the defined group charge the health plan member an agreed upon discounted fee. State means a State of the United States, the District of Columbia, Puerto Rico, the US Virgin Islands, or any territory or insular possession subject to the jurisdiction of the US. Uniform Act on Insurance Coverage of All Immunizations SLIDE 10 Slide 12 SECTION 2. SUBSTANCE OF THE ACT Covered Immunization Services To the extent permitted by federal law, any health benefit plan issued, renewed, extended, or modified for delivery in this state, must include at a minimum, immunizations as a covered benefit for all beneficiaries and their dependents, regardless of age according to the most recent schedules recommended by the Advisory Committee on Immunization Practices (ACIP), of the U.S. Department of Health and Human Services. Cost Sharing Provisions (A) Health Benefit Plans will pay 100% of the charges for the ACIP-Recommended immunizations. For purposes of this paragraph, charges include the cost of the biological product and any costs associated with the administration of such product. (1) (B) Health Benefit Plans subject to this act must explicitly provide these services, the services shall not be subject to any co-payment, coinsurance, deductible, or dollar limit provisions in the health benefit plan. (c)Network Provisions (1) Health benefit plans will cover all immunizations regardless of whether the immunization is obtained in or out of the plans network. Uniform Act on Insurance Coverage of All Immunizations SLIDE 11 Slide 13 SECTION 3. UNIFORMITY OF APPLICATION AND CONSTRUCTION In applying and construing this Uniform Act, consideration must be given to the need to promote uniformity of the law with respect to its subject matter among States that enact it. SECTION 4. SHORT TITLE. This [Act] may be cited as the Uniform Immunization Act. SECTION 5. SEVERABILITY CLAUSE. The provisions of this Act are severable. If any provision of this Act or its application is held invalid, that invalidity shall not affect other provisions or applications of this Act which can be given effect without regard to the provision or application that has been held to be invalid. SECTION 6. EFFECTIVE DATE. The provisions of this Act shall apply to any health benefit plan issued, renewed, extended, or modified for delivery in this state on or after: Options: (1) Date of enactment. A date (x) days after the date of enactment. (X) days after (insert description of regulations or other guidance) is issued by (insert name of administering agency) SECTION 7. APPLICATION TO EXISTING RELATIONSHIPS Drafter may want to include special rules that describe how the provisions of this Act apply to any health benefit plan issued, renewed, extended, or modified for delivery in this state before the effective date described in Section 6. Uniform Act on Insurance Coverage of All Immunizations SLIDE 12 Slide 14 Project Staff SLIDE 13 Alexandra Stewart, J.D. Director, Assistant Research Professor, Department of Health Policy 202-530-2331; stewarta@gwu.edustewarta@gwu.edu Marisa Cox, M.A., Research Associate, Department of Health Policy 202-530-2307; mcox@gwu.edumcox@gwu.edu Alexis Lee, J.D., Research Associate, Department of Health Policy 202-416-0413; alee1@gwu.edualee1@gwu.edu Phyllis Borzi, J.D., M.A., Research Professor, Department of Health Policy 202-530-2312; borziph@gwu.eduborziph@gwu.edu Sara Rosenbaum, J.D., Hirsh Professor and Chair, Department of Health Policy 202-530-2343; sarar@gwu.edusarar@gwu.edu FOR INFORMATION, PLEASE VISIT: www.gwhealthpolicy.org/immunizationwww.gwhealthpolicy.org/immunization