DC Guidance on Insurer Immunization Coverage

District of Columbia Department of Insurance, Securities and Banking 1050 First Street NE, Suite 801, Washington, DC 20002 • 202.727.8000 • disb@dc.gov • DISB.dc.gov BULLETIN 25-IB-003-09/17 TO: All Insurers Offering Health Benefit Plans in the District of Columbia FROM: Karima M. Woods, Commissioner RE: Guidance to Insurers on Immunization Coverage DATE: September 17, 2025 The DC Department of Insurance, Securities and Banking (“DISB”) is issuing this bulletin to clarify its expectations regarding immunization coverage requirements for vaccines within District of Columbia-issued health plans. Guidance To prevent individual cases and outbreaks of disease, the Advisory Committee on Immunization Practices (ACIP) recommendations as of December 31, 2024, presented the industry with a standard of care that was widely accepted and followed in clinical care. As such, carriers in the individual, small and large group markets in the District of Columbia are expected to continue to provide coverage for all vaccines and the cost to administer vaccines, without cost-sharing and without the use of any obstructive utilization management, for all immunizations recommended by ACIP as of December 31, 2024.1, This requirement includes age-appropriate, FDA approved COVID-19 vaccines for eligible individuals. As the American Academy of Pediatrics, the American College of Obstetricians and Gynecologists, the American Academy of Family Physicians, or other relevant medical organizations update their immunization schedules and recommendations in the future, the Department may issue further guidance. In the event immunizations and vaccines are designated by the District of Columbia Director of the Department of Health through a public notice, DISB expects such immunizations will be covered without cost-sharing in the individual, small and large group markets. This requirement does not apply to Medicare, certain self-funded arrangements, limited-scope benefit plans, or other excepted benefit plans. Recommended Adult Immunization Schedule for ages 19 years or older; 2025 U.S. Recommended Child and Adolescent Immunization Schedule for ages 18 years or younger; 2025 U.S.

District of Columbia Department of Insurance, Securities and Banking 1050 First Street NE, Suite 801, Washington, DC 20002 • 202.727.8000 • disb@dc.gov • DISB.dc.gov Background This bulletin provides interpretive guidance regarding the authority of the DISB Commissioner under Section 5002(b) of the Individual Health Insurance Requirement Amendment Act of 2018, effective October 30, 2018 (D.C. Law 22-168; D.C. Official Code § 47-5109 (a)(2)); Section 101(c) of the Federal Health Reform Implementation and Omnibus Amendment Act of 2014, effective May 2, 2015 (D.C. Law 20-265; D.C. Official Code § 31-3461(c)); Section 207 of the Health Insurance Portability and Accountability Federal Law Conformity and No-Fault Motor Vehicle Insurance Act of 1998, effective April 13, 1999 (D.C. Law 12-209; D.C. Official Code § 31- 3302.07); Mayor’s Order 2019-001, dated January 4, 2019; and Chapter 89 (Individual Responsibility Requirement) to Title 26-A DCMR (Insurance). Under federal law, and subsequently under District of Columbia rulemaking, to be recognized as minimum essential coverage under 45 C.F.R. § 156.604, a plan or policy must meet a “substantially all” standard where the plan complies with a set of provisions, including those set forth under PHS Act § 2707(a) - provision of essential health benefits (EHBs) (45 CFR Part 156 Subpart B) and PHS Act § 2713 - coverage of preventive health services (29 CFR § 2590.715- 2713). Questions Any questions or concerns regarding this Bulletin may be directed to the DISB Insurance Bureau by email at insurance.bureau@dc.gov or by phone at 202.727.8000.