Non-grandfathered plans are required under the Affordable Care Act (ACA) to cover certain in-network preventive care services and medications at no cost to the member.  As guidelines are updated, plans typically must adopt the new standard by the plan year that falls one year on/after the update.

On June 11, 2019, pre-exposure prophylaxis (PrEP) was given a high enough “A” rating to fall under these rules.  Therefore, non-grandfathered “plans must 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 or policy years beginning on or after June 30, 2020).”

Federal regulators have recognized that there may have been confusion in how this must be covered, so FAQ Part 47 provides three Q&As to offer additional clarity and time to comply.  “In consideration of the possibility that plans and issuers may not have understood that the regulatory coverage requirements apply to all support services of the USPSTF’s recommendation for pre-exposure prophylaxis (PrEP), the Departments will not take enforcement action against a plan or issuer for failing to provide coverage of such services through the period ending 60 days after publication of these FAQs, and encourage states to take a similar enforcement approach.”

The coverage requirements are outlined in the guidance to include the following:

  • Before prescribing PrEP, a medical history and HIV testing (as it’s not safe for persons with acute or chronic HIV infection)
  • At the time of or just before initiating PrEP, kidney function testing, serologic testing for hepatitis B and C virus, testing for other sexually transmitted infections (STI), and pregnancy testing (when appropriate)
  • After PrEP, ongoing follow-up and monitoring, including HIV testing every 3 months and adherence support (establishing trust and open communication with  patients, patient education, reminder systems for taking medication, and attention to medication adverse effects and having a plan to address them)
  • Office visits associated with each recommended preventive service

IMA will continue to monitor regulator guidance and offer meaningful, practical, timely information.

This material should not be considered as a substitute for legal, tax and/or actuarial advice. Contact the appropriate professional counsel for such matters. These materials are not exhaustive and are subject to possible changes in applicable laws, rules, and regulations and their interpretations.