NY Insurers Must Cover Immunizations at No Cost-Sharing

Insurance Circular Letter No. 5 (2025)

September 10, 2025

TO:  All Insurers Authorized to Write Accident and Health Insurance in New York State, Article 43 Corporations, Health Maintenance Organizations, Student Health Plans Certified Pursuant to Insurance Law § 1124, Municipal Cooperative Health Benefit Plans, and  Prepaid Health Services Plans.

RE:  Coverage of Immunizations

STATUTORY AND REGULATORY REFERENCES: N.Y. Insurance Law §§ 3216, 3221, and 4303 and 11 NYCRR § 52.76 ****

I. Background and Purpose

Public health experts at the New York State Department of Health have been clear that immunizations remain the safest way to protect New Yorkers from a long list of serious and potentially life-threatening illnesses by preparing the immune system to recognize and fight serious, and sometimes deadly, diseases. [1] They have concluded that due to immunizations, serious and often fatal diseases that were once common are no longer a pervasive threat to society. [2] Further, public health researchers have found that vaccines are a powerful tool at lowering health care costs by preventing illness and reducing mortality. [3] The purpose of this Circular Letter is to remind insurers authorized to write accident and health insurance in this state, Article 43 corporations, health maintenance organizations, student health plans certified pursuant to New York Insurance Law § 1124, municipal cooperative health benefit plans, and prepaid health services plans [4] (collectively, “issuers”) of requirements and expectations related to coverage of immunizations and their administration under health insurance policies and contracts.

II. State Law Requiring Coverage

The Insurance Law requires issuers to cover immunizations at no cost-sharing for children and adults that are provided by in-network providers.  Regardless of the age of the insured, Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3) require health insurance policies and contracts that provide hospital, surgical, or medical care coverage, except for a grandfathered health plan, [5] to cover, at no cost-sharing, preventive care and screenings that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Taskforce and immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices (“ACIP”).  Under 11 NYCRR § 52.76(a)(3), a policy or contract that covers preventive care and screenings specified in any recommendation or guideline described in Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3) must provide coverage through the last day of the policy or contract year, even if the recommendation or guideline changes during the policy or contract year. Given that public health officials have confirmed the importance of immunizations in maintaining the health of the public and in preventing diseases that add to health insurance costs, the Department strongly encourages all issuers to continue to cover the immunizations at no cost-sharing as recommended by ACIP as of the date of this Circular Letter for children and adults after the last day of the policy or contract year, even if the immunizations no longer have in effect a recommendation from ACIP.

For children, through the attainment of 19 years of age, Insurance Law §§ 3216(i)(17)(B)(ii) and (iii), 3221(l)(8)(B)(ii) and (iii), and 4303(j)(2)(B) and (C) require medical, major medical, and comprehensive health insurance policies and contracts, including grandfathered health plans, to cover immunizations, at no cost-sharing, if determined to be a necessary immunization by the Superintendent of Financial Services (“Superintendent”) in consultation with the Commissioner of Health (“Commissioner”).  As discussed in Insurance Circular Letter No. 3 (2020) and Insurance Circular Letter No. 16 (2020), the Superintendent, in consultation with the Commissioner, previously determined that COVID-19 immunizations for children through the attainment of 19 years of age are immunizations that must be covered by issuers. [6] Therefore, no matter any change in ACIP recommendations, issuers must cover COVID-19 immunizations for children through the attainment of 19 years of age without cost-sharing.

Circular Letter No. 13 (2006) made clear that issuers are required to cover immunizations recommended by ACIP for children through the attainment of 19 years of age and was intended to address situations when ACIP added recommended immunizations to the schedule.  This Circular Letter modifies Circular Letter No. 13 to not apply to the removal of recommendations.  As indicated above, the Department strongly encourages all issuers to continue to cover the immunizations at no cost-sharing as recommended by ACIP as of the date of this Circular Letter for children.

Issuers should also note that the Insurance Law’s prohibition on cost-sharing for immunizations for children and adults extends to any charge for administration of immunizations, any charge for the office visit when the primary purpose of the visit is an immunization or when the other services provided are preventive care services that are required to be covered under Insurance Law §§ 3216(i)(17), 3221(l)(8), and 4303(j) at no cost-sharing, and any related facility fee.

When issuers are acting as administrators for self-funded health benefit plans, the Department encourages issuers to encourage plan sponsors to take steps that are consistent with this Circular Letter. Plan sponsors should be made aware of the New York State Department of Health’s guidance, and issuers should encourage plan sponsors to follow the provisions of this Circular Letter for self-funded health benefit coverage in New York.

III. Conclusion

Issuers cover a wide variety of immunizations that are essential for public health and to reduce long term illness.  Issuers should continue to cover immunizations as outlined in this Circular Letter and in accordance with the Insurance Law and regulations promulgated thereunder.   Please direct any questions regarding this circular letter that relate to issuers by email at [email protected].

Very truly yours,

Lisette Johnson

Bureau Chief, Health Bureau

[1] See statement from the New York State Department of Health.

[2] Id.

[3] CDC. Health and Economic Benefits of Routine Childhood Immunizations in the Era of the Vaccines for Children Program – United States, 1994 – 2023. August 2024. Accessed on September 9, 2025.

[4] This Circular Letter does not apply to Medicaid managed care, Child Health Plus, and Essential Plan coverage.  The reference to prepaid health services plans only includes commercial insurance coverage written by such plans.

[5] A “grandfathered health plan” means coverage provided by an issuer in which an individual was enrolled on March 23, 2010, for as long as the coverage maintains grandfathered status in accordance with 42 U.S.C § 18011(e).  Ins. Law §§ 3216(i)(17)(F), 3221(l)(8)(G), 4303(j)(4).

[6] See the New York State Department of Health website for more information on the COVID-19 vaccine.