RSV Vaccine Coverage

Springfield Office 320 W. Washington Street Springfield, Illinois 62767 (217) 782-4515 Chicago Office 122 S. Michigan Ave., 19th Floor Chicago, Illinois 60603 (312) 814-2420 Illinois Department of Insurance JB PRITZKER Governor DANA POPISH SEVERINGHAUS Director TO: All Companies Writing Accident and Health Insurance and Managed Care Plans in Illinois FROM: Dana Popish Severinghaus, Director DATE: October 16, 2023 RE: Company Bulletin 2023-14 RSV Vaccine Coverage The Illinois Department of Insurance reminds insurers of their obligations to cover recommended preventive services, including vaccines for RSV, and compels insurers to streamline billing codes, consumer outreach, and coordination with pharmacy benefit managers (“PBMs”) and providers to provide timely coverage to consumers. The Department recognizes that, in some instances, the federal government has granted insurers an entire year before coverage is mandated. However, as consumers seek RSV vaccines to safeguard themselves through the fall and winter, the Department requests that insurers provide coverage of the RSV vaccine as soon as possible to keep Illinoisans healthy and safe. The federal Advisory Committee on Immunization Practices ("ACIP") approved the following recommendations which have been adopted by the CDC Director: RSV Vaccines for Older Adults – Recommended June 21, 2023 • Adults 60 years of age and older may receive a single dose of RSV vaccine, based on shared clinical decision-making between the patient and provider. RSV Monoclonal Antibody for Infants and Young Children – Recommended August 3, 2023 • Infants aged <8 months born during or entering their first RSV season are recommended to receive one dose of nirsevimab (50mg dose for infants <5kg in weight and 100 mg dose for infants >=5 kg). • Children aged 8 to 19 months who are at increased risk of severe RSV disease and entering their second RSV season are recommended to receive one dose of nirsevimab (200mg). • The monoclonal antibody can be administered in the hospital after the baby is born or in the outpatient setting. RSV Vaccines for Pregnant Persons – Recommended September 22, 2023 • Maternal RSV vaccine is recommended for pregnant persons during 32 through 36 weeks gestation, using seasonal administration (September through January), to prevent RSV lower respiratory tract infection in infants. Springfield Office 320 W. Washington Street Springfield, Illinois 62767 (217) 782-4515 Chicago Office 122 S. Michigan Ave., 19th Floor Chicago, Illinois 60603 (312) 814-2420 Under Affordable Care Act (“ACA”) 42 U.S. Code Section 300gg–13, issuers are required to cover any new or updated preventive care recommendation (including immunizations recommended by ACIP) without cost sharing when obtained from a network provider for plan years beginning on or after one (1) year from the date of the recommendation. All issuers will be required to comply with the recommendations above for non-grandfathered health plans issued on or after June 21, August 3, 2024 and September 22, 2024, respectively. On July 14, 2023, September 29, 2023, and October 13, 2023, the Illinois Department of Public Health (“IDPH”) endorsed the recommendations by the CDC’s ACIP and urged Illinoisans to get vaccinated to prevent the “tripledemic that caused a strain on resources in many hospitals, COVID-19, flu and RSV.” Given the importance of the RSV vaccine in preventing hospitalizations and severe health outcomes, the Illinois Department of Insurance (“IDOI”) urges issuers to take the following actions: 1. expedite incorporation of RSV vaccine coverage in plans; 2. allow enrollees the use of out-of-network pharmacies at the in-network benefit level of coverage in the event a shortage of vaccines at in-network clinical and pharmacy settings, as required under the Network Adequacy and Transparency Act (“NATA”); 3. increase communication between pharmacies/providers/facilities and issuers and/or PBMs to troubleshoot any potential billing issues; 4. consider all feasible and prudent options to reduce any barriers to accessing the vaccine, including but not limited to cost-sharing, reimbursement paperwork, clinical setting requirements, and network access; and 5. create and/or update RSV vaccine FAQ pages to provide clear guidance to enrollees on coverage, including how to identify in-network providers and instructions for seeking reimbursement. Additionally, IDOI reiterates the importance of issuers following guidance on COVID-19 vaccination coverage provided in CB 2023-12 and encourages issuers to also review policies and practices in place for enrollees to access flu shots as well. Questions about this Bulletin may be directed to DOI.InfoDesk@illinois.gov.