COST-SHARING PROTECTIONS FOR CONTRACEPTIVES AND PrEP, AND PrEP ENDORSEMENT REQUIRED

STATE OF NEW MEXICO OFFICE OF SUPERINTENDENT OF INSURANCE SUPERINTENDENT OF INSURANCE Russell Toal DEPUTY SUPERINTENDENT Jennifer A. Catechis Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 400, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us BULLETIN 2022-016 SEPTEMBER 12, 2022 TO: ALL HEALTH INSURANCE PLANS OFFERING MAJOR MEDICAL COVERAGE IN NEW MEXICO RE: COST-SHARING PROTECTIONS FOR CONTRACEPTIVES AND PrEP, AND PrEP ENDORSEMENT REQUIRED The New Mexico Office of Superintendent of Insurance (OSI) has recently received reports of individuals being charged cost-sharing - coinsurance, deductible and copayments - for contraceptives and contraceptive services. The Superintendent reminds issuers that cost-sharing of any kind for contraceptives and contraceptive services is prohibited by Sections 59A-22-42, 59A- 23-7.14, 59A-46-44, and 59A-47-45.5 NMSA 1978. Additionally, prior authorization for contraception and contraceptive services is not permitted pursuant to these laws. While cost-sharing prohibitions for contraceptives and contraceptive services are longstanding, the prohibition on cost-sharing for preexposure prophylaxis for HIV (PrEP) is more recent. On June 11, 2019, the United States Preventive Services Task Force (USPSTF) released its recommendation that clinicians offer PrEP with effective antiretroviral therapy to persons who are at high risk of HIV acquisition. The USPSTF gave its recommendation an “A” rating, which means a group health plan or health insurance issuer offering group or individual coverage is required, per the Affordable Care Act, to cover the item or service as preventive care. Pursuant to 45 C.F.R. §147.130 and 26 C.F.R. §54.9815-2713, coverage must be provided without any cost-sharing requirements (such as a copayment, coinsurance, or a deductible.) This requirement went into effect on June 30, 2020. On July 19, 2021, the United States Departments of Labor, Health and B U L L E T I N 2 0 2 2 - 0 1 6 P a g e | 2 Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us Human Services (HHS), and Treasury issued a frequently asked questions document which clarified that the cost-sharing prohibition for PrEP includes PrEP-related services.1 To assure that members who were erroneously charged cost-sharing for the services described above are identified and reimbursed, OSI is requiring that issuers audit their claims to identify any instances of inappropriate application of cost-sharing. For contraceptives and contraceptive services, issuers are to review claims with dates of service starting January 1, 2020. For PrEP and PrEP-related services, issuers are to review claims with dates of service starting June 30, 2020. In all cases, issuers will reimburse covered persons who are found to have been erroneously charged cost-sharing. Issuers are to submit a report to the Superintendent detailing the number of claims for which a covered person was erroneously charged cost-sharing for PrEP medication and PrEP- related services, the number of unique covered individuals affected by this oversight, the total dollar amount refunded to all covered individuals, and when the refund process was completed. Issuers should produce a separate report for erroneously applied cost-sharing for contraceptives and contraceptive services. The two reports shall be submitted to the Superintendent in letter format no later than December 31, 2022. OSI will not issue a reporting template. Reports shall be filed with Rolanda Pana at rolanda.pana@state.nm.us. Please note that if a health plan or health insurance issuer is exempt from Sections 59A- 22-42, 59A-23-7.14, 59A-46-44, and 59A-47-45.5 NMSA 1978 regarding contraceptive coverage, or 45 C.F.R. §147.130 and 26 C.F.R. §54.9815-2713 regarding PrEP coverage, a null report should not be filed with OSI. Finally, as part of OSI’s commitment to consumer protection, we work to ensure that issuers supply accurate and understandable information that clearly explains health insurance rights and benefits to consumers. OSI has found that the information provided in issuers’ Evidence of Coverage (EOC) documents varies in clarity and accuracy pertaining to the coverage of PrEP medication and PrEP-related services without cost-sharing. Therefore, the Superintendent is requiring the attached endorsement to be issued in conjunction with each EOC that was in effect 1 https://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/Downloads/FAQs-Part-47.pdf B U L L E T I N 2 0 2 2 - 0 1 6 P a g e | 3 Main Office: 1120 Paseo de Peralta, Room 428, Santa Fe, NM 87501 Satellite Office: 6200 Uptown Blvd NE, Suite 100, Albuquerque, NM 87110 Main Phone: (505) 827-4601 | Satellite Phone: (505) 322-2186 | Toll Free: (855) 4 - ASK - OSI www.osi.state.nm.us on or after June 30, 2020. Additionally, the language contained in the endorsement must be included in each newly issued EOC. Questions concerning this bulletin should be directed to Julie Weinberg at julie.weinberg2@state.nm.us. The OSI acknowledges that a recent federal district court in Texas took issue with the reproductive health and PrEP coverage requirements of the ACA. This ruling is being appealed. The OSI believes it essential to continue to offer these services to New Mexicans until there is final resolution on the matter. Thank you for your understanding and cooperation. ISSUED this 12th day of September, 2022. __________________________________ RUSSELL TOAL Superintendent of Insurance PRE-EXPOSURE PROPHYLAXIS COVERAGE SUMMARY ENDORSEMENT [NUMBER/IDENTIFIER] THIS ENDORSEMENT CHANGES YOUR AGREEMENT WITH US This endorsement summarizes HIV Pre-Exposure Prophylaxis (PrEP) medication coverage and essential PrEP services you are entitled to, and replaces any part of your insurance agreement with us that provides less favorable coverage: Pre-Exposure Prophylaxis (PrEP) Your plan includes coverage for PrEP medication, as appropriate for you, and essential PrEP related services without cost-sharing, the same as any other preventive drug or service. This means that you do not have to make a co-payment, pay coinsurance, satisfy a deductible or pay out-of-pocket for any part of the benefits and services listed in this summary if you receive them from an in-network provider. You may be required to pay a copay, coinsurance, and/or a deductible if you receive PrEP medication or PrEP related services from an out-of-network provider if the same benefit or service is available from an in-network provider. What is Covered? • At least one FDA-approved PrEP drug, with timely access to the PrEP drug that is medically appropriate for the enrollee, as needed • HIV testing • Hepatitis B and C testing • Creatinine testing and calculated estimated creatine clearance or glomerular filtration rate • Pregnancy testing for individuals with childbearing potential • Sexually transmitted infection screening and counseling • Adherence counseling • Office visits associated with each preventive service listed above • Quarterly testing for HIV and STIs, and annually for renal functions, required to maintain a PrEP prescription. Grievance and Appeals Process If you were charged cost-sharing for coverage of PrEP medication or PrEP related services on or after January 1st, 2021, please call our customer service line at [INSERT CUSTOMER SERVICE LINE HERE AND METHODS OF CONTACTING THE CARRIER TO FILE A MEMBER GRIEVANCE if the issue is not resolved at the customer service level] . If you are denied coverage of a PrEP related service(s), we will inform you in writing of the denial. Our notice to you will explain why we denied the coverage and will provide you with instructions for filing a grievance if you want to contest our decision. You, your designee, prescribing physician or other prescriber can request a standard or expedited review of a PrEP coverage denial [INSERT METHOD(S) OF CONTACTING THE CARRIER TO FILE A MEMBER GRIEVANCE HERE]. Exception Process If you have been denied coverage of a PrEP medication, we will inform you in writing of the denial. Our notice to you will provide you with instructions for filing an exception request if the medication that is most appropriate for your circumstances is not included in the drug formulary. You, your designee, prescribing physician or other prescriber can request a standard or expedited review of a PrEP medication coverage denial. [INSERT METHOD(S) OF CONTACTING THE CARRIER TO FILE A EXCEPTION REQUEST HERE]. . Standard Review • We will review your request and issue a determination to you, your designee, prescribing physician or other prescriber, within 72 hours following receipt of your request. Expedited Review • If you are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or if you are undergoing a current course of treatment using a non-formulary drug, you can request an expedited review. We will review your request and issue a determination to you, your designee, prescribing physician or other prescriber, within 24 hours following receipt of your request. If our initial determination is overturned, we will provide coverage for the PrEP medication or PrEP related service that is medically appropriate for you for the duration of the treatment. For more information or assistance with your complaint, grievance or an exception request, you may contact the Managed Health Care Bureau (MHCB), of the Office of Superintendent of Insurance at: Telephone: [1-833-415-0566] Office of Superintendent of Insurance - MHCB [P.O. Box 1689, 1120 Paseo de Peralta Santa Fe, NM 87504-1689 E-mail: mhcb.grievance@state.nm.us] This endorsement is retroactive back to the effective date of your coverage with us, or January 1, 2022, whichever comes first. These terms replace and supersede any conflicting provision of your insurance contract and summary of benefits and coverage. All other requirements of the policy not in conflict with this endorsement still apply.