FAQs Clarification: Covered Testing and Services re: PrEP

On July 19, 2021, the Departments of Labor, Health and Human Services (HHS), and the Treasury (collectively, the Departments) published a set of FAQs regarding the coverage of HIV Preexposure Prophylaxis (PrEP) as preventive care.

Background

The ACA requires non-grandfathered insurers and health plans to cover preventive care at 100% without cost sharing.  It defines preventive care, in part, as those services that are rated  “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF).

In 2019, the USPSTF issued a recommendation that clinicians offer PrEP with “effective antiretroviral therapy to persons who are at high risk of human immunodeficiency virus (HIV) acquisition.”  The recommendation came with a set of protocols including baseline and monitoring services, including:

• HIV testing;
• Hepatitis B and C testing;
• Creatinine testing;
• Pregnancy testing;
• Sexually transmitted infection (STI) screening and counseling; and
• Adherence counseling.

The FAQs

According to the FAQs, it appeared that many plans and insurers failed to understand that the coverage requirements applied to those testing and counseling services as well as the PReP medication itself.

• The FAQs clarify that those tests and services must be covered as part of the preventive care requirements.
• Plans and insurers may not use medical management techniques to alter the frequency of any test or service to the extent that the frequency is specified in the USPSTF recommendation.
• Conversely, plans and insurers may employ medical management to encourage individuals prescribed PrEP to use specific items and services, to the extent the frequency, method, treatment, or setting is not specified in the USPSTF recommendation.

The FAQs give plans and issuers 60 days from the date of publication to conform coverage to these requirements.

Click here for a copy of the FAQ.