Insights

New Supplemental Bulletin on Insurance Coverage for PrEP and HIV Screening


On July 23, 2019, the Department of Financial Services published Supplement No. 1 to Insurance Circular Letter No. 21 (2017). The bulletin reminds carriers of the requirements of Circular Letter No. 21, published back in 2017 (and covered in the January 9, 2018, edition of Compliance Corner here), which reminded carriers that coverage of pre-exposure prophylaxis (PrEP, used for HIV prevention) should be subject only to reasonable utilization management measures and must follow written clinical review criteria in a nondiscriminatory manner. This means that there’s no justification for denying coverage for PrEP on the ground that the patient is at risk for HIV based on sexual orientation.

According to the new supplemental bulletin, under NY law and the ACA, carriers must provide coverage for evidence-based care and screenings with an “A” or “B” rating (as recommended by the US Preventive Services Task Force (USPSTF)) with zero cost sharing for participants. On June 11, 2019, the USPSTF issued an “A” rating recommendation that clinicians offer PrEP with effective antiretroviral therapy to persons who are at high risk of HIV acquisition.

Now that offering PrEP with effective antiretroviral therapy to persons who are at high risk of HIV acquisition is an “A” rated recommendation, carriers (other than grandfathered health plans) must provide coverage for PrEP for the prevention of HIV at no cost sharing. NY carriers must provide this PrEP coverage without cost sharing as soon as possible, but no later than January 1, 2020, for policies or contracts that are issued on or after that date.

The bulletin contains no new employer compliance obligations. But employers should be aware of the PrEP coverage requirements.

Supplement No. 1 to Insurance Circular Letter No. 21 (2017) »