Sara Rosenbaum, JD, Alexandra Stewart, JD, Marisa Cox, MA, and Shawnte Mitchell. Department of Health Policy, The George Washington University Medical Center, 2021 K St, NW, Suite 800, Washington, DC 20006, 202-530-2331, stewarta@gwu.edu

This study is a descriptive, point-in-time examination of state insurance immunization coverage mandates, which affect approximately 100 million persons enrolled in state licensed health insurance organizations whose coverage standards are subject to state laws.

Utilizing standard legal research techniques, researchers conducted an on-line examination of state insurance laws that as of Winter 2003, regulated health insurance products sold in the state. First, researchers “unbundled” each statute into its components and compared each component against the elements of comprehensiveness: (a) whether coverage is mandated; (b) the age ranges and categories of enrollees covered by the mandate; (c) the standard of coverage used to define the mandate; (d) prohibitions against cost sharing; and (e) regulation of networks and payment rates. In the second stage, researchers “rebundled” the elements into four increasingly relaxed hypothetical statutory “composites” in order to measure how many state laws could be considered “comprehensive” in their totality.

Although the majority of states maintain immunization mandates, no state has enacted a comprehensive mandate - a law that mandates coverage during childhood and adolescence, requires adherence to ACIP standards, and prohibits the use of patient cost sharing (both deductibles and coinsurance). With three narrowly drawn exceptions, no state mandates coverage of adults. No state addresses the issue of insurer payment for provider immunization services through a replacement program or regulation of vaccine administration. Similarly, no state regulates insurer discretion over payment of out-of-network providers. No state law prohibits insurer exclusions when immunizations purportedly are available free of charge.

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