Enforcement Needed to Ensure Health-Plan Compliance With HIV Preventive Drug Requirement

As we begin 2021, almost everyone with private health insurance will have free access to drugs that prevent HIV infection, known as pre-exposure prophylaxis, or PrEP. To start with, it is remarkable that such medications exist, and so important that health care coverage laws emphasize preventive services.

However, we must ensure that people are aware of this opportunity and talk to their health care provider about accessing PrEP. Health insurers must do their part by making sure they offer the drug without cost-sharing, and government regulators must hold insurers accountable.

While insurers have had plenty of time to prepare for this obligation, a recent review conducted by the HIV+Hepatitis Policy Institute found that some health plans offered on federal and state exchanges for 2021 across the country are in violation of their legal requirement to offer PrEP without cost-sharing.

PrEP is a critical component to prevent HIV and reduce new infections and plays a crucial role in our nation’s effort to end HIV. Beginning this month, most health plans are required to provide PrEP without cost-sharing based on a June 2019 recommendation from the U.S. Preventive Services Task Force.

PrEP requires a prescription from a provider, and periodic doctor visits, lab tests and HIV and hepatitis testing per guidelines from the Centers for Disease Control and Prevention and the Food and Drug Administration.

Under the Affordable Care Act, insurers must offer USPSTF-recommended services without cost-sharing in the plan year that begins one year after the date of the recommendation – in this case, 2021.

More than a year ago, members of the HIV community wrote to all state insurance commissioners and the U.S. Department of Health and Human Services to urge them to take steps to ensure payor compliance with these requirements.

New York’s insurance regulator acted quickly by requiring compliance one year earlier, and issued an order that all ancillary services, such as office visits and lab tests associated with PrEP usage, be covered without cost-sharing.

California’s insurance commissioner also issued guidance that requires plans to cover all PrEP drugs without prior authorization, along with ancillary services without cost-sharing. Colorado has taken steps to ensure plans are meeting this requirement and encouraged them to cover the associated services without cost-sharing.

While these state efforts should be applauded, all state insurance commissioners must take steps to ensure compliance and admonish insurers that are violating the law. Federal guidance and enforcement are also needed.

While the past administration began drafting such guidance, the Biden administration must finalize and issue it. It can begin by quickly updating the list of preventive services all health plans must cover, which still does not include PrEP. As part of any guidance, the Biden administration must make it clear that all PrEP-associated services must also be included without cost-sharing. This is very similar to the ancillary services that are required as part of other preventive service, such as colonoscopies.

Our analysis of the plans also found that too many insurers are not transparent in displaying the zero-cost-sharing information for PrEP and there is no consistency among insurers. Because uptake of PrEP has been slow in certain populations, including among black and Latino gay men and black women, it is critical that insurers not make it more difficult to access PrEP.

We in the HIV community, together with public health leaders, have been working for years to get to the day when insured people who are at risk of HIV can access PrEP without cost-sharing. We trust that the new Biden administration shares this commitment and will work with state regulators to ensure insurers keep up their legal requirements under the ACA.

Carl Schmid is the executive director of the HIV+Hepatitis Policy Institute and co-chair of the Presidential Advisory Council of HIV/AIDS.

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