Insights

Guidance Addresses Coverage for Monkeypox Virus Testing, Diagnosis and Immunization


On August 31, 2022, the Department of Financial Services (DFS) issued Circular Letter No. 12 to advise health insurers of the coverage requirements for monkeypox virus testing, diagnosis and immunization. The memo follows Gov. Hochul’s declaration of a state disaster emergency to combat the spread of the monkeypox virus on July 29, 2022, and the issuance of Executive Order No. 20.1 (EO 20.1) on August 28, 2022. EO 20.1 was issued to ensure that health insurance coverage requirements and cost-sharing do not impede monkeypox virus immunization, testing and diagnosis.

Generally, state insurance laws require individual, small group and large group comprehensive health insurance policies, excluding grandfathered health plans, to provide coverage at no cost-sharing for immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention. However, EO 20.1 ensures that insurers cover the monkeypox virus vaccine and administration for all eligible persons, including persons covered under grandfathered plans, regardless of whether they fall within the specific ACIP recommendation. EO 20.1 temporarily modifies the state insurance laws to require coverage of the monkeypox virus immunization and administration without any cost-sharing when provided in-network or out-of-network.

With respect to monkeypox virus testing and diagnosis, EO 20.1 temporarily modifies state insurance laws governing small and large group coverage requirements to waive cost-sharing for in-network laboratory testing to diagnose the monkeypox virus; and visits to diagnose the monkeypox virus at 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. Insurers must provide written notification to 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, as permitted by law. Additionally, a deductible may be applied for high deductible health plans if otherwise required by law.

The letter also reminds insurers that an otherwise covered service, including the diagnosis of the monkeypox virus, cannot be excluded due to delivery via telehealth and must be reimbursed on the same basis and at the same rate as when delivered in person. Insurers must also maintain an adequate network to meet telehealth needs. Finally, the letter emphasizes that insurers should dedicate resources to providing accurate and timely coverage information to covered individuals, including making all necessary and useful information available on websites.

Although the letter is primarily directed at insurers, employers that offer group health coverage issued in New York should be aware of the updated coverage requirements.

Insurer Circular Letter No. 12 »