Coverage requirements

(a) Private insurance (1) In general Section 2713(a) of the Public Health Service Act (42 U.S.C. 300gg–13(a)) is amended— (A) in paragraph (2), by striking; and and inserting a semicolon; (B) in paragraph (3), by striking the period and inserting a semicolon; (C) in paragraph (4), by striking the period and inserting; and; (D) by striking paragraph (5); (E) by adding at the end the following: (5) any prescription drug approved by the Food and Drug Administration used for the prevention of HIV (other than a drug subject to preauthorization requirements consistent with section 2729A–11), administrative fees for such drugs, laboratory and other diagnostic procedures associated with the use of such drugs, and clinical follow-up and monitoring, including any related services recommended in current United States Public Health Service clinical practice guidelines, including policy notes updating those guidelines, without limitation.; and (F) by adding at the end of the flush text at the end the following: For the purposes of this Act, and for the purposes of any other provision of law, the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention shall be considered the most current other than those issued in or around November 2009.. (2) Grandfathered plans Section 1251(a)(4) of the Patient Protection and Affordable Care Act (42 U.S.C. 18011(a)(4)) is amended by adding at the end the following: (v) Section 2713(a)(5) (relating to coverage without cost-sharing for prescription drugs for the prevention of HIV).. (3) Prohibition on preauthorization requirements (A) PHSA Part D of title XXVII of the Public Health Service Act (42 U.S.C. 300gg–111 et seq.) is amended by adding at the end the following: 2799A–12. Prohibition on preauthorization requirements with respect to certain services A group health plan or a health insurance issuer offering group or individual health insurance coverage shall not impose any preauthorization requirements with respect to coverage of the services described in section 2713(a)(5), except that a plan or issuer may impose preauthorization requirements with respect to coverage of a particular drug approved under section 505(c) of the Federal Food, Drug, and Cosmetic Act or section 351(a) of this Act if such plan or issuer provides coverage without any preauthorization requirements for a drug that is therapeutically equivalent.. (B) ERISA (i) In general Subpart B of part 7 of subtitle B of title I of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1185 et seq.) is amended by adding at the end the following: 727. Prohibition on preauthorization requirements with respect to certain services A group health plan or a health insurance issuer offering group health insurance coverage shall not impose any preauthorization requirements with respect to coverage of the services described in section 2713(a)(5) of the Public Health Service Act, except that a plan or issuer may impose preauthorization requirements with respect to coverage of a particular drug approved under section 505(c) of the Federal Food, Drug, and Cosmetic Act or section 351(a) of the Public Health Service Act if such plan or issuer provides coverage without any preauthorization requirements for a drug that is therapeutically equivalent.. (ii) Clerical amendment The table of contents in section 1 of the Employee Retirement Income Security Act of 1974 (29 U.S.C. 1001 et seq.) is amended by inserting after the item relating to section 726 the following new item: Sec. 727. Prohibition on preauthorization requirements with respect to certain services.. (C) IRC (i) In general Chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end of subchapter B the following: 9827. Prohibition on preauthorization requirements with respect to certain services A group health plan shall not impose any preauthorization requirements with respect to coverage of the services described in section 2713(a)(5) of the Public Health Service Act, except that a plan may impose preauthorization requirements with respect to coverage of a particular drug approved under section 505(c) of the Federal Food, Drug, and Cosmetic Act or section 351(a) of the Public Health Service Act if such plan provides coverage without any preauthorization requirements for a drug that is therapeutically equivalent.. (ii) Clerical amendment The table of sections for subchapter B of chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end the following new item: Sec. 9827. Prohibition on preauthorization requirements with respect to certain services.. (b) Coverage under Federal Employees Health Benefits program Section 8904 of title 5, United States Code, is amended by adding at the end the following: (c) Any health benefits plan offered under this chapter shall include benefits for, and may not impose any cost-sharing requirements for any prescription drug approved by the Food and Drug Administration used for the prevention of HIV, administrative fees for such drugs, laboratory and other diagnostic procedures associated with the use of such drugs, and clinical follow-up and monitoring, including any related services recommended in current United States Public Health Service clinical practice guidelines, including policy notes updating those guidelines, without limitation.. (c) Medicaid (1) In general Section 1905 of the Social Security Act (42 U.S.C. 1396d) is amended by— (A) in subsection (a)(4), by striking the semicolon at the end and inserting; and (G) HIV prevention services;; and (B) by adding at the end the following new subsection: (ll) HIV prevention services For purposes of subsection (a)(4)(G), the term HIV prevention services means all prescription drugs used for the prevention of HIV acquisition, administrative fees for such drugs, laboratory and other diagnostic procedures associated with the use of such drugs, and clinical follow-up and monitoring, including any related services recommended in current United States Public Health Service clinical practice guidelines, including policy notes updating those guidelines without limitation.. (2) No cost-sharing Title XIX of the Social Security Act (42 U.S.C. 1396 et seq.) is amended— (A) in section 1916, by inserting HIV prevention services described in section 1905(a)(4)(G), after section 1905(a)(4)(C), each place it appears; and (B) in section 1916A(b)(3)(B), by adding at the end the following new clause: (xv) HIV prevention services described in section 1905(a)(4)(G).. (3) Inclusion in benchmark coverage Section 1937(b)(7) of the Social Security Act (42 U.S.C. 1396u–7(b)(7)) is amended— (A) in the paragraph heading, by inserting and HIV prevention services after supplies; and (B) by striking includes for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section and inserting includes medical assistance for HIV prevention services described in section 1905(a)(4)(G), and includes, for any individual described in section 1905(a)(4)(C), medical assistance for family planning services and supplies in accordance with such section. (d) CHIP (1) In general Section 2103 of the Social Security Act (42 U.S.C. 1397cc) is amended— (A) in subsection (a), in the matter preceding paragraph (1), by striking and (8) and inserting (8), and (13); and (B) in subsection (c), by adding at the end the following new paragraph: (13) HIV prevention services Regardless of the type of coverage elected by a State under subsection (a), the child health assistance provided for a targeted low-income child, and, in the case of a State that elects to provide pregnancy-related assistance pursuant to section 2112, the pregnancy-related assistance provided for a targeted low-income pregnant woman (as such terms are defined for purposes of such section), shall include coverage of HIV prevention services (as defined in section 1905(ll)).. (2) No cost-sharing Section 2103(e)(2) of the Social Security Act (42 U.S.C. 1397cc(e)(2)) is amended— (A) in the paragraph heading, by inserting HIV prevention services, after treatment,; and (B) by inserting HIV prevention services described in subsection (c)(13), before or for pregnancy-related assistance. (3) Effective date (A) In general Subject to subparagraph (B), the amendments made by subsection (c) and this subsection shall take effect on January 1, 2027. (B) Delay permitted if State legislation required In the case of a State plan approved under title XIX or XXI of the Social Security Act which the Secretary of Health and Human Services determines requires State legislation (other than legislation appropriating funds) in order for the plan to meet the additional requirements imposed by this section, the State plan shall not be regarded as failing to comply with the requirements of such title solely on the basis of the failure of the plan to meet such additional requirements before the 1st day of the 1st calendar quarter beginning after the close of the 1st regular session of the State legislature that ends after the 1-year period beginning with the date of enactment of this section. For purposes of the preceding sentence, in the case of a State that has a 2-year legislative session, each year of the session is deemed to be a separate regular session of the State legislature. (e) Coverage and elimination of cost-Sharing under Medicare (1) Coverage of HIV prevention services under Part B (A) Coverage (i) In general Section 1861(s)(2) of the Social Security Act (42 U.S.C. 1395x(s)(2)) is amended— (I) in subparagraph (JJ), by striking and at the end; (II) in subparagraph (KK), by inserting and at the end; and (III) by adding at the end the following new subparagraph: (LL) HIV prevention services (as defined in subsection (ooo));. (ii) Definition Section 1861 of the Social Security Act (42 U.S.C. 1395x) is amended by adding at the end the following new subsection: (ooo) HIV prevention services The term HIV prevention services means— (1) drugs or biologicals approved by the Food and Drug Administration for the prevention of HIV; (2) administrative fees for such drugs; (3) laboratory and other diagnostic procedures associated with the use of such drugs; and (4) clinical follow-up and monitoring, including any related services recommended in current United States Public Health Service clinical practice guidelines, including policy notes updating those guidelines, without limitation.. (B) Elimination of coinsurance Section 1833(a)(1) of the Social Security Act (42 U.S.C. 1395l(a)(1)) is amended— (i) by striking and (HH) and inserting (HH); and (ii) by inserting before the semicolon at the end the following:, and (II) with respect to HIV prevention services (as defined in section 1861(ooo)), the amount paid shall be 100 percent of (i) except as provided in clause (ii), the lesser of the actual charge for the service or the amount determined under the fee schedule that applies to such services under this part, and (ii) in the case of such services that are covered OPD services (as defined in subsection (t)(1)(B)), the amount determined under subsection (t). (C) Exemption from Part B deductible The first sentence of section 1833(b) of the Social Security Act (42 U.S.C. 1395l(b)) is amended— (i) by striking, and (13) and inserting (13); and (ii) by striking 1861(n).. and inserting 1861(n), and (14) such deductible shall not apply with respect to HIV prevention services (as defined in section 1861(ooo)(1)).. (D) Effective date The amendments made by this paragraph shall apply to items and services furnished on or after January 1, 2027. (2) Elimination of cost-sharing for drugs for the prevention of HIV under part D (A) In general Section 1860D–2 of the Social Security Act (42 U.S.C. 1395w–102) is amended— (i) in subsection (b)— (I) in paragraph (1)(A), by striking and (9) and inserting, (9), and (10); (II) in paragraph (2)— (aa) in subparagraph (A), by striking and (9) and inserting, (9), and (10); (bb) in subparagraph (C)(i), in the matter preceding subclause (I), by striking and (9) and inserting (9), and (10); and (cc) in subparagraph (D)(i), in the matter preceding subclause (I), by striking and (9) and inserting (9), and (10); (III) in paragraph (3)(A), in the matter preceding clause (i), by striking and (9) and inserting (9), and (10); (IV) in paragraph (4)(A)(i), by striking and (9) and inserting, (9), and (10); and (V) by adding at the end the following new paragraph: (10) Elimination of cost-sharing for drugs for the prevention of HIV For plan years beginning on or after January 1, 2027, with respect to a covered part D drug that is for the prevention of HIV— (A) the deductible under paragraph (1) shall not apply; and (B) there shall be no coinsurance or other cost-sharing under this part with respect to such drug.; and (ii) in subsection (c), by adding at the end the following new paragraph: (7) Treatment of cost-sharing for drugs for the prevention of HIV The coverage is provided in accordance with subsection (b)(10).. (B) Conforming amendments to cost-sharing for low-income individuals Section 1860D–14(a) of the Social Security Act (42 U.S.C. 1395w–114(a)) is amended— (i) in paragraph (1)(D), in each of clauses (ii) and (iii), by striking paragraph (6) and inserting paragraphs (6) and (7); (ii) in paragraph (2)— (I) in subparagraph (B), by striking and (9) and inserting, (9), and (10); (II) in subparagraph (D), by striking paragraph (6) and inserting paragraphs (6) and (7); and (III) in subparagraph (E), by striking paragraph (6) and inserting paragraphs (6) and (7); and (iii) by adding at the end the following new paragraph: (7) No application of cost-sharing or deductible for drugs for the prevention of HIV For plan years beginning on or after January 1, 2027, with respect to a covered part D drug that is for the prevention of HIV— (A) the deductible under section 1860D–2(b)(1) shall not apply; and (B) there shall be no cost-sharing under this section with respect to such drug.. (f) Coverage of HIV prevention treatment by Department of Veterans Affairs (1) Elimination of medication copayments Section 1722A(a) of title 38, United States Code, is amended by adding at the end the following new paragraph: (5) Paragraph (1) does not apply to a medication for the prevention of HIV.. (2) Elimination of hospital care and medical services copayments Section 1710 of such title is amended— (A) in subsection (f)— (i) by redesignating paragraph (5) as paragraph (6); and (ii) by inserting after paragraph (4) the following new paragraph (5): (5) A veteran shall not be liable to the United States under this subsection for any amounts for laboratory and other diagnostic procedures associated with the use of any prescription drug approved by the Food and Drug Administration and used for the prevention of HIV, administrative fees for such a drug, or clinical follow-up and monitoring, including any related services recommended in current United States Public Health Service clinical practice guidelines, including policy notes updating those guidelines, without limitation.; and (B) in subsection (g)(3), by adding at the end the following new subparagraph: (C) Any prescription drug approved by the Food and Drug Administration and used for the prevention of HIV, administrative fees for such a drug, laboratory and other diagnostic procedures associated with the use of such a drug, and clinical follow-up and monitoring, including any related services recommended in current United States Public Health Service clinical practice guidelines, including policy notes updating those guidelines, without limitation.. (3) Inclusion as preventive health service Section 1701(9) of such title is amended— (A) in subparagraph (K), by striking; and and inserting a semicolon; (B) by redesignating subparagraph (L) as subparagraph (M); and (C) by inserting after subparagraph (K) the following new subparagraph (L): (L) any prescription drug approved by the Food and Drug Administration and used for the prevention of HIV, administrative fees for such a drug, laboratory and other diagnostic procedures associated with the use of such a drug, and clinical follow-up and monitoring, including any related services recommended in current United States Public Health Service clinical practice guidelines, including policy notes updating those guidelines, without limitation; and. (g) Coverage of HIV prevention treatment by Department of Defense (1) In general Chapter 55 of title 10, United States Code, is amended by inserting after section 1074o the following new section: 1074p. Coverage of HIV prevention treatment (a) In general The Secretary of Defense shall ensure coverage under the TRICARE program of HIV prevention treatment described in subsection (b) for any beneficiary under section 1074(a) of this title. (b) HIV prevention treatment described HIV prevention treatment described in this subsection includes any prescription drug approved by the Food and Drug Administration and used for the prevention of HIV, administrative fees for such a drug, laboratory and other diagnostic procedures associated with the use of such a drug, and clinical follow-up and monitoring, including any related services recommended in current United States Public Health Service clinical practice guidelines, including policy notes updating those guidelines, without limitation. (c) No cost-Sharing Notwithstanding section 1075, 1075a, or 1074g(a)(6) of this title or any other provision of law, there is no cost-sharing requirement for HIV prevention treatment covered under this section.. (2) Clerical amendment The table of sections at the beginning of such chapter is amended by inserting after the item relating to section 1074o the following new item: 1074p. Coverage of HIV prevention treatment.. (h) Indian Health Service testing, monitoring, and prescription drugs for the prevention of HIV Title II of the Indian Health Care Improvement Act is amended by inserting after section 223 (25 U.S.C. 1621v) the following: 224. Testing, monitoring, and prescription drugs for the prevention of HIV (a) In general The Secretary, acting through the Director of HIV/AIDS Prevention and Treatment under section 832, shall provide, without limitation, funding for any prescription drug approved by the Food and Drug Administration for the prevention of human immunodeficiency virus (commonly known as HIV), administrative fees for that drug, laboratory and other diagnostic procedures associated with the use of that drug, and clinical follow-up and monitoring, including any related services recommended in current Public Health Service clinical practice guidelines, including policy notes updating those guidelines. (b) Authorization of appropriations There are authorized to be appropriated such sums as are necessary to carry out this section.. (i) Effective date The amendments made by subsections (a), (b), (e), (f), (g), and (h) shall take effect with respect to plan years beginning on or after January 1, 2027.