OR DFR Bulletin 2022-04: Covering the costs of hMPXV (human monkeypox virus) vaccination

350 Winter St. NE, Rm 410, P.O. Box 14480, Salem, OR 97309 503-378-4140 dfr.oregon.gov 1 Oregon Department of Consumer and Business Services Division of Financial Regulation, Bulletin No. DFR 2022-4 TO: All entities offering health benefit plans DATE: Aug. 10, 2022 RE: Covering the costs of hMPXV (human monkeypox virus) vaccination Purpose: The bulletin clarifies the division’s expectations for coverage of hMPXV vaccination by health benefit plans in Oregon. Background: The virus hMPXV, more commonly known as the monkeypox virus, is a type of Orthopoxvirus with symptoms that include fever, rash, and swollen lymph nodes. The virus has an estimated 1 percent case-fatality rate in endemic countries and the potential of higher rates among immunocompromised people. The virus is transmitted to humans through close contact with an infected person or animal, or with material contaminated with the virus. It is then transmitted from one person to another by close contact with lesions, body fluids, respiratory droplets, and contaminated materials such as bedding. Most infections in the current outbreak appear to be due to skin-to-skin contact. On July 23, 2022, the International Health Regulations Emergency Committee of the World Health Organization declared that the recent multi-country outbreak of the monkeypox virus constitutes a Public Health Emergency of International Concern (PHEIC). On Aug. 4, 2022, U.S. Health and Human Services Secretary Xavier Becerra determined that a Public Health Emergency (PHE) exists across the United States due to the outbreak of monkeypox cases across multiple states. On Aug. 5, 2022, pursuant to ORS 743A.264, the Oregon Health Authority issued a public health director’s declaration (OHA public health declaration) stating that an outbreak of viral illness caused by hMPXV is occurring in Oregon and that vaccination is necessary to prevent the spread of hMPXV. ORS 743A.264 prohibits health benefit plans from restricting coverage for the cost of necessary treatments, vaccines, immunizing agents, pharmaceutical agents, medical supplies, or other prophylactic measures approved by the U.S. Food and Drug Administration that the public health director deems necessary to prevent the spread of a disease. Guidance for health benefit plans The Division of Financial Regulation issues the following guidance to insurers regarding the division’s expectations for coverage in light of the OHA public health declaration: 2 • Coverage required – In accordance with ORS 743A.264(2), all health benefit plans (including grandfathered health benefit plans) in Oregon must provide coverage for approved hMPXV vaccines and their administration in accordance with this bulletin. The coverage required under this bulletin includes vaccines administered to an individual after exposure to the virus as post-exposure prophylaxis (PEP). • Network restrictions – In accordance with ORS 743B.264(3)(a), a health benefit plan may not restrict coverage for an approved hMPXV vaccine and its administration to innetwork providers. Health benefit plans must provide coverage for an hMPXV vaccine in accordance with this bulletin, regardless of whether an enrollee receives the vaccine from an in-network or out-of-network provider. The division encourages health benefit plans to be proactive in including approved vaccinators in their networks and to update operational systems to accept and process out of network vaccine claims. • Cost sharing – In accordance with ORS 743B.264(3)(b), a health benefit plan may not impose any cost sharing requirements, such as a co-pay, co-insurance, or deductible, on the coverage required under this bulletin. Coverage for hMPXV vaccines and their administration is to be provided without cost sharing both in and out of network. • Prior authorization and utilization review – In accordance with ORS 743B.264(3)(c), a health benefit plan may not require prior authorization or apply any other form of utilization review to the coverage of hMPXV vaccines and their administration. • All other coverage limits prohibited – In accordance with ORS 743B.264(3)(d), a health benefit plan may not impose any other limitation on the coverage required by this bulletin that serves, in form or in substance, to prevent an enrollee from receiving a hMPXV vaccine at no out-of-pocket cost. The commissioner encourages all health insurance plans not subject to ORS 743A.264 to also provide coverage in accordance with this bulletin. This bulletin is retroactive to Aug. 5, 2022, the date of the OHA declaration. The division intends to issue additional guidance on expectations for health insurers and health benefit plans related to hMPXV vaccination as the distribution process evolves. Dated this 10th day of August, 2022 at Salem, Oregon. ________________________________ ________________________ Andrew R. Stolfi Date Insurance Commissioner and Director Department of Consumer and Business Services 8/10/2022