IRS Issues FAQs Concerning Mandatory HIV PreP Coverage

The ACA requires non-grandfathered group health plans to provide coverage for certain preventive care services or items with no cost-sharing provision for the participant. A service or item is covered by this mandate one year after one or more of the following events take place:

• The United States Preventive Services Task Force (USPSTF) recommends the service or item with an “A” or “B” rating.
• The Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention recommend the immunization for routine use in children, adolescents and/or adults.
• The Health Resources and Services Administration (HRSA) supports the screening with respect to infants, children and adolescents.
• The HRSA supports the preventive care or screening for women.

In June 2019, the USPSTF released a recommendation with an “A” rating that clinicians offer pre-exposure prophylaxis (PrEP) with “effective antiretroviral therapy to persons who are at high risk of human immunodeficiency virus (HIV) acquisition.” Accordingly, plans and issuers must cover PrEP for plan years beginning on or after June 30, 2020.

In Part 47 of the ACA Implementation FAQs, issued on July 19, 2021, the DOL, HHS and Treasury Department clarify that coverage must include not only the medication itself, but also the following related services to improve the efficacy.

• HIV testing
• Hepatitis B and C testing
• Creatinine testing and calculated estimated creatinine clearance (eCrCl) or glomerular
• Filtration rate (eGFR)
• Pregnancy testing
• Sexually transmitted infection (STI) screening and counseling
• Counseling for assessment of behavior and adherence to CDC guidelines

If plans are not currently in compliance, plan sponsors should work with insurers and TPAs to amend the plan accordingly. The agencies will take a non-enforcement approach through September 16, 2021.

ACA Implementation FAQs, Part 47 »