Richard H. Hughes, IV, Member of the Firm in the Health Care & Life Sciences practice, in the firm’s Washington, DC, office, authored an article in Health Affairs, titled “The Task Force’s Latest PrEP Recommendation for HIV Is Just More of the Same.”
Following is an excerpt:
A little specificity would go a long way in the recommendations of the US Preventive Services Task Force (USPSTF)—that is, if we want health insurance companies to pay for lifesaving HIV prevention and patients to have access to it.
An editorial accompanying the Task Force’s new recommendation statement for pre-exposure prophylaxis (PrEP) for HIV in the August issue of JAMA poses the question, “New USPSTF guidelines for HIV preexposure prophylaxis: Will more choices lead to greater impact?” The answer under current Affordable Care Act (ACA) implementing rules is, “No.”
Under the federal rules that implement the ACA’s preventive services coverage requirement, payers are only required to cover the specific items and services recommended by the Task Force with an A or B grade. That means that, even with an A grade recommendation, the Task Force’s broadly worded recommendations for PrEP for HIV will be subject to vast payer discretion over which PrEP products will be covered. This is likely to impede patient access—unless the Centers for Medicare and Medicaid Services (CMS) steps in to clarify that payers must cover new forms of PrEP.
