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.
The plans required to cover PrEP include Obamacare and employer-sponsored group insurance policies, but corporate self-funded plans — in which the employer, rather than an outside insurer, directly pays for the insured enrollee’s eligible expenses — as well as out-of-state plans are exempt from these requirements because they fall outside of the state’s jurisdiction. Self-funded plans are largely governed by federal rather than state law.
Meanwhile, the administration’s guide regarding gender-affirming care spells out the treatments insurers must cover and which insurance plans are required to cover them. The same insurers required to cover PrEP without cost-sharing must also provide the outlined gender-affirming care.
Significantly, employer self-funded plans cover 5.2 million New Yorkers compared to the 3.7 million people covered by individual, small group, and large group commercial plans, meaning those who are not covered by the protections outnumber those who are covered.
“With these actions, we are removing a major financial barrier for people who want to take a proven HIV prevention drug and ensuring people have the information they need at their fingertips to access quality healthcare,” Cuomo said in a written statement. “These policies support our nation-leading campaign to end the AIDS epidemic in New York by the end of 2020 and ensure every New Yorker — regardless of sexual orientation or gender identity — gets the healthcare protections guaranteed to them under law.”
The success of the state’s effort to bring AIDS to an end as an epidemic will be based largely on getting those who are HIV-positive into treatment so they are no longer infectious while having people at risk for transmission take PrEP.
In addition to the robust initiatives regarding PrEP and gender-affirming care, the administration also proposed a regulation requiring insurers to provide more relevant information on healthcare ID cards such as coverage details, co-payment costs, and other necessary information.
Lastly, the administration reminded New Yorkers that no matter the actions of the federal government, the state bans discrimination on the basis of gender identity and sexual orientation in areas including access to health insurance.
The Cuomo administration’s moves come amid growing frustration over the state of health insurance nationwide, with premiums growing more expensive while plans fail to cover some necessary health services. The Trump administration’s scaling back of LGBTQ healthcare protections has only compounded existing anxieties surrounding access to care.
The effort to reign in the cost of PrEP follows vociferous calls by HIV/ AIDS advocates and the wider LGBTQ community to improve access to a drug that costs far more in the United States than in many other parts of the world.
“By requiring that PrEP be covered without cost-sharing, Governor Cuomo is allowing more New Yorkers to take control of their sexual health, which will save millions of taxpayer dollars associated with treating HIV,” said Amida Care CEO Doug Wirth, whose organization is a not-for-profit health plan that specializes in providing comprehensive coverage and care for New Yorkers with HIV, behavioral health disorders, and other complex conditions. “Additionally, arming New Yorkers with vital insurance information and guaranteeing that everyone, regardless of sexual orientation or gender identity, is protected from discrimination in healthcare settings will help remove barriers to healthcare faced by too many in the LGBTQ community.”
The Cuomo administration’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.
“We will continue to use our full authority to push back against federal efforts to roll back coverage and ensure that New Yorkers receive the healthcare they deserve without discrimination, regardless of sexual orientation, gender identity or expression,” DFS superintendent Linda Lacewell said.
