HPV vaccine: your health plan must cover it, and not only for girls

It is the HPV vaccine coverage mandate in Puerto Rico’s health plans. The statement of motives explains the public health rationale: cervical infection with human papillomavirus is a sexually transmitted disease and the main risk factor for cervical cancer; two strains, HPV-16 and HPV-18, are responsible for 70% of cervical cancer cases, and the vaccine also protects against two other virus types causing 90% of genital wart cases. The title under which OGP catalogs the law reflects the amendment: "for Males and Females".

People insured under a health plan in Puerto Rico — males and females — per the ACIP and CDC recommendations, which the amended law adopts as the criterion. The law applies to insurers and health service organizations under the Insurance Code and to plans providing services through the Health Insurance Administration.

• Being insured under a health plan subject to the law: insurers and health service organizations under the Insurance Code, or plans providing services through Act 72-1993.Verified against the official source
• That vaccination is indicated per the ACIP and CDC recommendations, which are the criterion the law adopts.Verified against the official source

Information pending verification.

1. 1

   Step 1: Know it is no longer "girls only"

   The original 2010 law asked for the vaccine for insured females between eleven (11) and eighteen (18), and that is where the widespread belief that it is a female vaccine comes from. The amendment by Act 255-2012 rewrote the operative article: it now orders coverage to include the HPV vaccine for males and females, per ACIP and CDC recommendations. The very title under which OGP catalogs the law reflects it.

2. 2

   Step 2: Demand the full series, not the first dose

   This is the point that prevents a surprise bill midway through: as part of their coverage, insurers shall include, without this constituting a limitation, access to the HPV vaccination treatment, which shall consist of the totality of the doses required by the Food and Drug Administration to achieve immunization. The coverage is of the complete schedule.

3. 3

   Step 3: Ask about the age per ACIP and CDC, not the old law’s

   The amended law does not itself set an age range: it defers to the recommendations of the Advisory Committee on Immunization Practices (ACIP) and the Centers for Disease Control and Prevention (CDC). Those recommendations change with the evidence, so the age applicable to your case is determined by current clinical criteria, not by the number that appeared in the 2010 version.

4. 4

   Step 4: Check that your plan is among those covered

   The order goes to all insurers, to health service organizations organized under Act 77-1957 (Puerto Rico Insurance Code) and to insurance plans providing services through Act 72-1993 (Puerto Rico Health Insurance Administration). That is, it covers both the private sector regulated by the Insurance Code and plans operating through ASES.

5. 5

   Step 5: If it is denied or billed to you, claim

   Denial of a benefit the law mandates is a coverage dispute. The Office of the Insurance Commissioner is the forum for complaints against insurers, and the Insurance Consumer Bill of Rights and the patient’s bill of rights give you the framework for the claim — we cover them in their own guides. Bring the record of the denial or the bill.

Coverage is claimed first with your health plan. For complaints against insurers, the Office of the Insurance Commissioner; if the matter concerns the Government Health Plan, the Health Insurance Administration is the one contracting those plans. The law provided that its application to each health plan occurs as they are sold or renewed, subject to approval by the Rate and Health Plan Review Board.

• Believing the HPV vaccine is only for girls: since the 2012 amendment the coverage is for males and females.
• Accepting one covered dose and being billed for the rest: the coverage is the totality of the doses the FDA requires to achieve immunization.
• Using the 11-to-18 range as if still in force: the amended law defers to the ACIP and CDC recommendations.
• Thinking it only applies to private plans: it also covers plans providing services through the Health Insurance Administration.
• Not requesting the denial in writing: it is what supports the complaint before the Insurance Commissioner.

These are the government pages this guide is based on.

• Oficina del Comisionado de Seguros (OCS)

  OCS

  bvirtualogp.pr.gov