Merkley is committed to PrEP users
On Thursday, US Senator from Oregon Jeff Merkley and Tina Smith (D-MN) were joined by Senators Chris Van Hollen (D-MD), Elizabeth Warren (D-MA), Bernie Sanders (I-VT), Tammy Baldwin (D-WI), Edward J. Markey (D-MA), and Cory Booker (D-NJ) in a letter to AHIP, the trade association representing health insurance companies. The letter expresses concern about the continuing practice of illegally billing people for pre-exposure prophylaxis (PrEP) drugs and related care.
The senators’ letter follows a court ruling on Wednesday that further threatens affordable access to PrEP. As the legal process progresses, the senators urged the health insurance industry to comply with existing law to provide free medication and ancillary services.
“It has come to our attention that people enrolled in your members’ health plans continue to be charged for necessary medications and ancillary services, including provider consultations and laboratory services, contrary to the law and to additional federal guidance issued by the Departments of Labor, Health and Human Services, and Treasury,” the senators wrote. “We are writing to express our deep concern over these erroneous and unlawful accusations, and to request additional information about the steps AHIP is taking to ensure that its members adhere to federal law and ensure that PrEP drugs and l all PrEP ancillary services are offered. free of charge for subscribers.
A 2019 decision by the US Preventive Services Task Force (USPSTF) gave PrEP an “A” grade as a prevention intervention for people at risk of contracting the human immunodeficiency virus (HIV). This decision placed PrEP under Section 2713 of the Public Health Services Act, which requires insurance coverage for services or procedures that have received an “A” or “B” rating from the USPSTF. .
Subsequent guidelines, released by the Centers for Medicare & Medicaid Services (CMS) in July 2021, further clarified their decision. Noting that “plans and issuers must cover PrEP in accordance with the USPSTF recommendation without cost sharing,” the decision goes on to clarify that PrEP is not just the drug, but also all of its necessary related services, including testing, screening and provider visits. Despite this decision and subsequent clarifications, people are still being wrongly charged for out-of-pocket expenses related to their PrEP care.
“In light of these clear guidelines from CMS, we are alarmed by continuing reports that patients are routinely being billed, either for full payment or for cost-sharing practices, related to medically appropriate medicines and services. essential,” they continued. “These costs can be daunting. HIV advocates and clinical workers across the county have reported that many patients are unaware that they don’t have to pay out-of-pocket for PrEP and ancillary services, assuming that many of those costs are simply needed to be on PrEP.
The senators’ letter highlights inequities in PrEP uptake among communities most at risk for HIV, including black and Hispanic communities and transgender women, due to limited access to the financial resources needed to cover the costs of PrEP and associated medical visits and laboratory tests, among others. The factors.
In light of these concerns, lawmakers are asking the following questions and requesting a response from AHIP within 30 days:
- What information or guidance does AHIP currently provide to help its members ensure their health plans comply with federal regulations specifying that PrEP and ancillary services must be available at no cost to patients?
- What information and educational materials does AHIP recommend its members provide to enrollees to ensure that patients know that PrEP, including its ancillary services, should be provided free of charge to enrollees?
- How does AHIP work with laboratories and healthcare providers to ensure the accurate coding of appointments and services so enrollees are not incorrectly billed for these services?
- How is AHIP working with its partners to develop a full understanding of the scale of the problem, both in terms of the number of people affected and the monetary impacts of incorrect billing?
- How does AHIP work with its members to quickly resolve issues for consumers who have been incorrectly billed for PrEP and related services?
The letter is supported by PrEP4ALL, HIV+Hepatitis Policy Institute, Center for Health and Democracy and NMAC.
“Unfortunately, we have documented dozens of cases of insurers still charging patients out-of-pocket costs for PrEP-related care, a year after CMS and the Department of Labor issued their guidelines,” said Kenyon Farrow, director. General of Advocacy & Organizing with PrEP4ALL. “To end the HIV epidemic, we will need to ensure that all insured people can benefit from PrEP services without cost sharing, as the rule requires. We applaud the tireless advocacy of Senator Merkley and Senator Smith on behalf of patients.
“We appreciate the leadership of Senators Merkley and Smith and all of their colleagues to ensure that the preventive services provisions of the Affordable Care Act are properly implemented. Private insurers must provide PrEP drugs and related services without cost sharing with the patient. We get too many complaints from PrEP users that this doesn’t always happen. We are confident that with this letter insurers will ensure full compliance,” said Carl Schmid, executive director of the HIV+Hepatitis Policy Institute.
“While appalling, it is sadly not shocking to see a large health insurer incorrectly billing enrollees for drugs and ancillary services as part of a PrEP regimen to prevent HIV, despite clear guidance from government departments. of Health and Human Services, Labor and the Treasury for not doing it,” said Wendell Potter, President of the Center for Health and Democracy. “We are grateful for the leadership of Senators Merkley and Smith in sending this letter, emphasizing their understanding of the effectiveness of PrEP and their compassion for those at risk and their families.”