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

July 23, 2019

TO: All Insurers Authorized to Write Accident and Health Insurance in New York State, Article 43 Corporations, Health Maintenance Organizations, Student Health Plans Certified Pursuant to Insurance Law § 1124, and Municipal Cooperative Health Benefit Plans
RE: Health Insurance Coverage for Pre-exposure Prophylaxis (“PrEP”) for the Prevention of Human Immunodeficiency Virus (“HIV”) Infection and for HIV Screening

STATUTORY REFERENCES:  N.Y. Insurance Law §§ 3216, 3221, and 4303

I. Purpose

This circular letter provides guidance to insurers authorized to write accident and health insurance in this state, Article 43 corporations, health maintenance organizations, student health plans certified pursuant to Insurance Law § 1124, and municipal cooperative health benefit plans (collectively “issuers”) regarding New York state requirements for health insurance coverage of PrEP for the prevention of HIV infection and for health insurance coverage of HIV screening.  Issuers must strictly comply with all statutory and regulatory requirements for providing this coverage.  This circular letter supplements Insurance Circular Letter No. 21 (2017) issued on December 1, 2017.

II. Discussion

Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3) require issuers that deliver or issue for delivery an insurance policy or contract in New York providing hospital, surgical, or medical care coverage, except for a grandfathered health plan,[1] to provide coverage for preventive care and screenings at no cost-sharing.  The Insurance Law requires, among other things, that issuers provide coverage for evidence-based care and screenings with an “A” or “B” rating in the current recommendations of the United States Preventive Services Task Force (“USPSTF”) at no cost-sharing.

On June 11, 2019, the USPSTF issued an “A” rated recommendation that clinicians offer PrEP with effective antiretroviral therapy to persons who are at high risk of HIV acquisition.  According to the full recommendation statement, the USPSTF found convincing evidence that PrEP is of substantial benefit for decreasing the risk of HIV infection in persons at high risk of HIV infection, either via sexual acquisition or through injection drug use.  The USPSTF also found convincing evidence that adherence to PrEP is highly correlated with its efficacy in preventing the acquisition of HIV infection.  In conjunction with the issuance of the recommendation on PrEP, the USPSTF also updated their 2013 recommendation on screening for HIV infection.  The USPSTF continues to strongly recommend, with an “A” rating, screening for HIV infection in adolescents and adults aged 15 to 65 years, younger adolescents and older adults at increased risk, and all pregnant persons, including those persons who present in labor or at delivery whose HIV status is unknown.

Coverage for PrEP for the prevention of HIV infection, along with screening for HIV infection, is vital to ending the AIDS epidemic.  According to the Centers for Disease Control and Prevention, almost 40,000 new HIV infections were diagnosed in 2017 in the United States.[2]  Prior to the USPSTF recommendation on PrEP, grandfathered and non-grandfathered plans that cover prescription drugs should have been covering PrEP under their prescription drug benefit, but could impose cost-sharing.  However, now that offering PrEP with effective antiretroviral therapy to persons who are at high risk of HIV acquisition is an “A” rated recommendation, issuers, other than grandfathered health plans, must provide coverage for PrEP for the prevention of HIV infection at no cost-sharing pursuant to Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3).  This will remove insurance barriers and ensure that New Yorkers have access to this important preventive medication.  The Department of Financial Services (“Department”) expects issuers, other than grandfathered plans, to provide coverage for PrEP with effective antiretroviral therapy at no cost-sharing to persons who are at high risk of HIV acquisition as soon as possible, but no later than January 1, 2020, for policies or contracts that are issued or renewed on or after that date.

III. Conclusion

In accordance with Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3), all issuers, except for grandfathered health plans, must provide coverage for PrEP for the prevention of HIV infection at no cost-sharing and cover screening for HIV infection at no cost-sharing.  Coverage for PrEP for the prevention of HIV infection is vital to ending the AIDS epidemic in New York, and the Department will continue to ensure full compliance with this important consumer health protection.

Please direct any questions regarding this circular letter to Colleen Rumsey, Supervising Insurance Attorney, by mail at New York State Department of Financial Services, Health Bureau, One Commerce Plaza, 19th Floor, Albany, New York 12257, or by email at [email protected]

Very truly yours,

 

Lisette Johnson
Bureau Chief, Health Bureau


[1] A “grandfathered health plan” means coverage provided by an issuer in which an individual was enrolled on March 23, 2010, for as long as the coverage maintains grandfathered status in accordance with 42 U.S.C § 18011(e).  Ins. Law §§ 3216(i)(17)(F), 3221(l)(8)(G), and 4303(j)(4).

[2] Centers for Disease Control and Prevention, HIV Surveillance Report, 2017, vol. 29, published November 2018, available at http://www.cdc.gov/hiv/library/reports/hiv-surveillance.html.