N.J. Admin. Code § 8:57-8.4

Current through Register Vol. 56, No. 11, June 3, 2024

Section 8:57-8.4 - Immunizations that must be covered

(a) A carrier shall provide benefits or services covering the expenses of immunizations for children as set forth in (b) below, including the costs of immunobiologics and administration of the immunizations, except that nothing in this subsection shall be construed to require a carrier to exceed its negotiated fee or the usual and customary fee for services rendered in the administration of an immunization.

(b) A carrier shall provide services or benefits for:

1. Immunizations specified in the "2007 Recommended Childhood and Adolescent Immunization Schedule," and described in the ACIP Recommendations, as set forth at 8:57-8.2(a);

2. All routine childhood vaccines as specified in the "2007 Recommended Childhood and Adolescent Immunization Schedule," and as described in the ACIP Recommendations:

i. In single or combined form;

ii. Pediatric diphtheria tetanus toxoid (DT) when a medical contraindication to DTP or DTaP exists;

iii. Single antigen measles or rubella vaccine, or measles and rubella (MR) vaccine when medically indicated or recommended;

iv. Hepatitis B immune globulin (HBIG) given concurrently with hepatitis B vaccine when medically indicated for newborns of mothers with HBsAG positive status, or unknown HBsAG status, or other close family contacts as determined by known risk factors; and

v. Influenza, hepatitis A, pneumococal, or other vaccines as recommended by the CDC for high risk children; and

3. Such immunizations as are recommended or mandated by the Commissioner, as the case may be, including post-exposure prophylactic doses, in the event that the Commissioner declares that an outbreak of a communicable disease exists or is threatened for which an immunization or program of immunizations is available.

(c) Carriers shall provide benefits or services for immunizations to be the same extent as for other medical conditions under the health benefits plan, except that no carrier shall require satisfaction of any deductible, in whole or in part, prior to the provision of benefits or services for immunizations to covered children.

1. A carrier may require payment of a co-payment to the extent that the co-payment shall not exceed the co-payment for other similar services, except that no co-payment shall apply to a Medicaid enrolled child participating in either Plan A, Plan B, Plan C, or Plan D of the New Jersey Medicaid or NJ FamilyCare Programs.

(d) Carriers shall not deny benefits or services for immunizations provided to a covered child at an age that is later than that set forth in the "2007 Recommended Childhood and Adolescent Immunization Schedule," and as described in the ACIP Recommendations, as set forth at 8:57-8.2, if the immunization is otherwise necessary to complete the schedule of immunizations for that child as specified in the "2007 Recommended Childhood and Adolescent Immunization Schedule," and as described in the ACIP Recommendations.

(e) Carriers shall provide benefits or services for doses which have to be repeated because previous doses received by a covered child are considered invalid by the DHSS due to administration before the medically recommended time, or due to administration prior to the recommended time interval between immunizations.

N.J. Admin. Code § 8:57-8.4

Recodified from N.J.A.C. 8:57-8.3 and amended by R.2009 d.107, effective 4/6/2009.
See: 40 N.J.R. 1962(a), 41 N.J.R. 1419(a).
Rewrote (b)1 and the introductory paragraph of (b)2; in (b)2v, substituted "; and" for period at end; in (b)3, inserted "by the Commissioner" and deleted ", or his or her designee" preceding "declares that"; recodified the last sentence of (c) as (c)1; in (c)1, substituted "NJ FamilyCare" for "New Jersey KidCare"; and rewrote (d). Former N.J.A.C. 8:57-8.3, Immunizations that must be covered recodified to N.J.A.C. 8:57-8.4.