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FAQs Released to Clarify Preventative Coverage Guidelines for HIV PrEP

Wednesday, August 25, 2021
Natalie Terchek

The Departments of Health and Human Services (HHS), Labor (DOL) and the Treasury (Departments) recently issued frequently asked questions (FAQs) about preventive care coverage requirements for HIV Preexposure Prophylaxis (PrEP) under the Affordable Care Act (ACA). The FAQs were released on July 19, 2021.

The ACA requires group health plans and insurers to cover certain items and services in the current recommendations of the United States Preventive Services Task Force (USPSTF) without cost sharing. On June 11, 2019, the USPSTF released a recommendation for HIV PrEP, which requires plans and issuers to cover HIV PrEP without cost sharing for plan years beginning on or after June 30, 2020.

Important Dates
  • June 11, 2019: The USPSTF issued a preventative care recommendation for HIV PrEP.
  • June 30, 2020: Plans and issuers must cover HIV PrEP without cost sharing for plan years beginning on or after June 30, 2020.
  • September 17, 2021: The deadline for full compliance with the FAQ guidance is 60 days after FAQ publication.
FAQ Guidance

The Departments’ guidance includes three FAQs that clarify the preventive care coverage requirements for HIV PrEP. According to these FAQs:

  • Plans and issuers are required to provide coverage without cost sharing for items or services that the USPSTF recommends should be received by a participant, beneficiary or enrollee prior to being prescribed anti-retroviral medication as part of the determination of whether that medication is appropriate for the individual and for ongoing follow-up and monitoring. This includes baseline and monitoring services such as HIV testing, Hepatitis B and C testing, creatinine testing, pregnancy testing, sexually transmitted infection (STI) screening and counseling, and adherence counseling.
  • The USPSTF PrEP recommendation specifies the frequency of certain services for individuals specified in the recommendation. Plans and issuers may use reasonable medical management techniques to determine the frequency, method, treatment or setting for the provision of a recommended preventive service only to the extent not specified in the applicable recommendation.

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