Supplement No. 2 to
Insurance Circular Letter No. 21 (2017)
October 8, 2020
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
Health Insurance Coverage for Pre-exposure Prophylaxis (“PrEP”) for the Prevention of Human Immunodeficiency Virus (“HIV”) Infection and Testing and Ongoing Follow-up and Monitoring Related Thereto
STATUTORY REFERENCES: N.Y. Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3)
The purpose of this circular letter is to provide guidance to 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 (collectively “issuers”) regarding New York State requirements for health insurance coverage for PrEP, tests and services expressly recommended before prescribing PrEP, and ongoing follow-up and monitoring related thereto. This circular letter supplements Insurance Circular Letter No. 21 (2017) issued on December 1, 2017 and Supplement No.1 to Insurance Circular Letter No. 21 (2019) issued on July 23, 2019.
Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3) require issuers, other than grandfathered health plans, to cover items or services at no cost-sharing that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Taskforce (“USPSTF”). Supplement No. 1 to Insurance Circular Letter No. 21 (2019) advised issuers that 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. Therefore issuers, other than grandfathered health plans, must provide coverage for PrEP for the prevention of HIV infection to persons at high risk of HIV acquisition at no cost-sharing.
This circular letter further advises issuers that, in the absence of any specific federal guidance to the contrary, any tests or services that are expressly recommended in the Other Considerations, Implementation section of the USPSTF’s Final Recommendation Summary for PrEP (“USPSTF Summary”) to be provided to a person at high risk of HIV acquisition prior to prescribing PrEP or as ongoing follow-up and monitoring also must be covered at no-cost sharing pursuant to Insurance Law §§ 3216(i)(17)(E), 3221(l)(8)(E) and (F), and 4303(j)(3). At the time of publication of this circular letter, the Ongoing Considerations, Implementation section of the USPSTF Summary provides in relevant part that:
[b]efore prescribing PrEP, clinicians should exclude persons with acute or chronic HIV infection through taking a medical history and HIV testing. The 2-drug antiretroviral regimen used in PrEP, when used alone, is not an effective treatment for HIV infection, and its use in persons living with HIV can lead to the emergence of, or selection for, drug-resistant HIV infection. It is also generally recommended that kidney function testing, serologic testing for hepatitis B and C virus, testing for other STIs, and pregnancy testing (when appropriate) be conducted at the time of or just before initiating PrEP. Ongoing follow-up and monitoring, including HIV testing every 3 months, is also suggested.
Issuers should keep abreast of any updates to the USPSTF Summary and provide coverage with no cost-sharing accordingly.
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 at no cost-sharing. The requirement to provide coverage for PrEP at no cost-sharing extends to the tests and services that are recommended by the USPSTF to be undertaken prior to prescribing PrEP and for ongoing follow-up and monitoring. Ensuring that people who may benefit from PrEP are able to access and afford testing and related services is vital, and the Department of Financial Services will continue to ensure full compliance with this circular letter, Insurance Circular Letter No. 21 (2017), and Supplement No.1 to Insurance Circular Letter No. 21 (2019).
Please direct any questions regarding this circular letter to Thomas Fusco, Supervising Insurance Attorney, by email at [email protected].
Very truly yours,
Bureau Chief, Health Bureau
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).