Federal agencies have issued frequently asked questions (FAQ) guidance explaining how non-grandfathered health insurance plans must provide preventive care benefits to people at high risk of contracting the human immunodeficiency virus (HIV). The FAQs focus on HIV Pre-Exposure Prophylaxis (PrEP) services specifically, but also address how plans may generally apply medical cost management practices to Affordable Care Act (ACA) preventive care coverage. Plans must comply within 60 days (by September 17, 2021).
The FAQs clarify that when a preventive care recommendation like PrEP includes multiple components of care, plans should cover all parts without cost-sharing.
ACA requires all non-grandfathered plan to cover specific preventive care services without applying participant cost-sharing requirements. The list of preventive care services that plans must cover on a first-dollar basis includes services that have an “A” or “B” rating in the current recommendations of the United States Preventive Services Task Force (USPSTF).
On June 10, 2019, the USPSTF released a recommendation with an “A” rating that clinicians offer PrEP with “effective antiretroviral therapy to persons who are at high risk of human immunodeficiency virus (HIV) acquisition.” The recommendation describes PrEP as a comprehensive intervention comprised of both antiretroviral medication and essential support services. The support care includes a clinical assessment to ensure the therapy is appropriate for the individual, and also covers a variety of screening tests and medication adherence counseling. When offered as part of PrEP, all these services qualify as preventive care under the ACA.
Accordingly, plans had to start to cover PrEP consistent with the USPSTF recommendation without cost sharing for plan years beginning on or after one year from the issue date of the recommendation (in this case, plan years beginning on or after June 30, 2020). However, some plans only covered antiretroviral therapy on a first-dollar basis and not all related services.
Since many carriers and plans did not fully understand the scope of the requirement before the publication of these FAQs, the agencies will not take enforcement action against a plan for failing to provide coverage for the full range of necessary services through the period ending 60 days after publication of the FAQs.
The FAQs also address how plans can legally apply medical management to PrEP specifically and preventive care in general.
Reasonable limits on the frequency, method, treatment, or setting of preventive care are permitted if the relevant federal guidelines do not address them. The USPSTF recommendation addresses the frequency of some PrEP services, so a plan needs to follow those guidelines. However, the recommendation does not require the use of brand-name medications. So while a branded version of PrEP does not need to be provided at no cost sharing generally, it must be provided at no cost sharing if generic forms of PrEP are deemed medically inappropriate by the individual’s health care provider
These guidelines are valid for PrEP and they are also transferable to medical management for all ACA preventive care services.
Conner Strong & Buckelew will work with our clients and carriers/partners to confirm implementation of these requirements. Please contact your Conner Strong & Buckelew account representative toll-free at 1-877-861-3220 with any questions. For a complete list of Legislative Updates issued by Conner Strong & Buckelew, visit our online Resource Center.