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NYS Requires PrEP Coverage by Insurers
 
 
  "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."
 
"New York state will require health insurance companies to cover the cost of treatments to detect and prevent HIV infection starting next year, according to a letter circulated by the Department of Financial Services."
 
"The Cuomo administra¬tion's Department of Financial Services (DFS), which is responsible for overseeing the insurance industry, is carrying out much of the work to implement the changes. The agency sent a letter to insurers directing them to cover PrEP, saying they "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. The proposed rule improving healthcare ID cards also came through DFS via a proposed rule."Under a package of initiatives rolled out by the Cuomo administration on July 23, out-of-pocket PrEP costs are being eliminated in health insurance plans that cover millions of New Yorkers and a new guide outlines the gender-affirming care insurers must cover.
 
Under the changes announced by Governor Andrew Cuomo, insurers governed by New York State regulation will be required to provide PrEP as well as HIV screenings without cost-sharing, meaning folks will be able to access the HIV prevention medication without spending anything on co-pays or toward satisfying their deductibles."
https://www.gaycitynews.nyc/stories/2019/17/cuomo-prep-gender-affirming-care-2019-07-25-gcn.html
 
https://www.dfs.ny.gov/industry_guidance/circular_letters/cl2019_s01_cl2017_21
 

allInsurers

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 colleen.rumsey@dfs.ny.gov.
Very truly yours,
 
Lisette Johnson
Bureau Chief, Health Bureau
 
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[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.
 
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NYS plans to make HIV prevention drug free through insurance
 
By Brett Dahlberg • Jul 25, 2019
 
New York state will require health insurance companies to cover the cost of treatments to detect and prevent HIV infection starting next year, according to a letter circulated by the Department of Financial Services.
 
https://news.wbfo.org/post/nys-plans-make-hiv-prevention-drug-free-through-insurance
 
New York state will require health insurance companies to cover the cost of treatments to detect and prevent HIV infection starting next year, according to a letter circulated by the Department of Financial Services.
 
A key part of the state's plan to end the AIDS epidemic is wider access to the drug PrEP, which prevents HIV transmission.
 
PrEP is a daily pill that has been on the market for years, but still runs more than a thousand dollars a month, said Ashley Zuppelli, the director of innovation at Trillium Health.
 
That means for people on high-deductible insurance plans, it can be prohibitively expensive, and even for people with lower deductibles, it can add up quickly.
 
Cost reduction strategies have hinged on voluntary arrangements. The drug's manufacturer offers copay coupons to some patients, and some insurance companies choose to accept those coupons. Zuppelli said because this system is voluntary, it's inherently unstable. That's set to change, though: The state Department of Financial Services sent a letter to insurance companies on Tuesday saying it would require them to cover PrEP at no cost to patients.
 
"It is really exciting," Zuppelli said. "I think it really opens the doors and allows people to access the preventive health care that they really deserve."
 
Financial barriers or a lack of knowledge about the drug have kept populations who are vulnerable to HIV transmission from using PrEP, said Zuppelli. Now, she said, she expects the dropping of financial barriers and increased awareness brought by the state's action to turn that around.
 
The new rule is scheduled to go into effect on Jan. 1, 2020, but in its letter, the state encouraged insurers to update their policies "as soon as possible."
 
Rochester's two biggest health insurance providers, MVP Health Care and Excellus BlueCross/BlueShield, both said Wednesday that they were reviewing the new regulations and figuring out how their insurance offerings would change to fit the rules.
 
 
 
 
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