HR5127-119

What This Bill Does

The PrEP and PEP are Prevention Act makes HIV prevention services a no-cost covered benefit across major health coverage programs. Private group health plans and issuers must cover FDA-approved HIV prevention drugs, including PrEP and PEP, administrative fees, labs and diagnostics, HIV prevention counseling, risk assessment, risk reduction, medication adherence, clinical follow-up, monitoring, and related services recommended by Public Health Service guidelines. Plans generally cannot impose preauthorization on those services unless they cover a therapeutically equivalent drug without preauthorization. Medicare adds HIV prevention services as a covered medical service, pays 100 percent under applicable fee schedules or outpatient department payment, and waives the deductible. Part D removes deductibles, coinsurance, and cost-sharing for covered HIV prevention drugs. Medicaid adds HIV prevention services, bars cost-sharing, and applies to benchmark coverage. CHIP must cover HIV prevention services for targeted low-income children and pregnancy-related assistance where elected. FEHB plans must include benefits for HIV prevention drugs and related services without cost-sharing. The effective dates generally begin with the first plan year or first calendar year after enactment, with state-plan delay rules when state legislation is required.

Who Benefits and How

People using PrEP benefit because private plans, Medicare, Medicaid, CHIP, and FEHB must cover preventive drugs and related services without cost-sharing. People needing PEP benefit from no-cost coverage after potential HIV exposure. HIV prevention clinics benefit from coverage of counseling, labs, monitoring, administrative fees, and follow-up services. Low-income Medicaid enrollees benefit from coverage and cost-sharing protections for HIV prevention services. FEHB enrollees benefit from explicit no-cost HIV prevention drug and service coverage.

Who Bears the Burden and How

Private health insurers must cover HIV prevention services and limit preauthorization barriers. Medicare Part D plans must waive deductibles and cost-sharing for covered HIV prevention drugs. State Medicaid agencies must update state plans, benchmark coverage, and cost-sharing rules. Federal employee health plans must add no-cost HIV prevention benefits. Federal taxpayers and premium payers bear higher coverage costs if utilization increases.

Key Provisions

• Requires private health plans to cover PrEP, PEP, related drugs, administration, labs, counseling, follow-up, and monitoring without limitation.
• Limits preauthorization unless a therapeutically equivalent drug is covered without preauthorization.
• Adds Medicare coverage with 100 percent payment and no deductible for HIV prevention services.
• Removes Part D deductible, coinsurance, and cost-sharing for HIV prevention drugs.
• Adds Medicaid, benchmark, CHIP, pregnancy-related assistance, and FEHB coverage with cost-sharing protections.