LGBTQ Agenda: Lara responds to report finding insurers making PrEP access more difficult

  • by John Ferrannini, Assistant Editor
  • Tuesday August 29, 2023
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California Insurance Commissioner Ricardo Lara says that his office has already implemented some of the recommendations in a report calling on regulators to make PrEP access easier.
California Insurance Commissioner Ricardo Lara says that his office has already implemented some of the recommendations in a report calling on regulators to make PrEP access easier.

Gay California Insurance Commissioner Ricardo Lara's office is responding to a report showing how insurers prevent patients from using preventative care mandated under federal law, including PrEP.

The report, issued August 4 from the National Association of Insurance Commissioners, also outlines six ways government regulators can improve access to preventative services.

PrEP, or pre-exposure prophylaxis, refers to the use of antiviral drugs to prevent people exposed to HIV from becoming infected. The pill Truvada was first approved for PrEP use in 2012 by the federal Food and Drug Administration; since then the FDA has also approved the pill Descovy for some groups, and the drug Apretude as an injectable treatment. According to federal Centers for Disease Control and Prevention statistics, only 25% of the approximately 1.2 million Americans who could benefit from PrEP had prescriptions in 2020.

"Under Commissioner Lara's direction the Department of Insurance is a national leader in protecting and expanding access to HIV prevention including PrEP, working alongside LGBTQ+ community groups and advocates," Michael Soller, Lara's deputy commissioner of communications and press relations, stated to the Bay Area Reporter.

Even so, PrEP coverage is under threat, as the B.A.R. previously reported. The Patient Protection and Affordable Care Act mandates coverage of preventative care as recommended by the United States Preventive Services Task Force. However, the plaintiffs in Braidwood Management v. Xavier Becerra have sued the federal government alleging that covering PrEP violates their constitutional right to religious freedom.

Covering PrEP makes the business owners who filed the case "complicit in facilitating homosexual behavior, drug use, and sexual activity outside of marriage between one man and one woman," according to their civil complaint. The coverage mandate remains nationwide, except for the plaintiffs, while the case works its way through the courts. (It's currently at the 5th U.S. Circuit Court of Appeals.)


The National Association of Insurance Commissioners report itself states, "the ways that insurers organize and expose information to providers and consumers is a meaningful barrier to effective understanding and use of preventive service benefits."

This includes official documents having "incomplete information about coverage" and inconsistency in how information about cost sharing was displayed.

"While regulators have not historically taken a direct oversight role in how insurers organize information for the public, we believe oversight is necessary to ensure that consumers and providers can practically access and use information they need to understand coverage and billing rules," the report stated.

The six recommendations to insurance regulators are that they increase state resources to review and act on claims adjudication data; ensure continued ACA preventive service coverage and cost-sharing protections through state legislative and regulatory action; enforce appeals protections for mis-adjudicated or denied preventive services claims; and ensure that Qualified Health Plan certification processes adequately assess formularies and other plan documents for preventive services requirements compliance.

The report also recommends that regulators hold plans accountable for educating consumers and providers on preventive services requirements, utilize data calls and market conduct exams to assess compliance and the claims process; and establish uniform billing and coding standards.

Soller stated that Lara and the California Department of Insurance have already implemented some of these recommendations.

"Several of the recommendations by consumer groups to the NAIC mirror steps we have taken through executive actions and sponsoring legislation," Soller stated. "We are always looking for ways to remove barriers to accessing zero-dollar preventive services and strengthen state law. We have also done [a] review of formularies to ensure that they include preventive drugs like PrEP, statins, smoking cessation drugs, and contraceptives."

These actions included issuing a bulletin to insurance companies on December 29, 2021 expressly detailing to them their obligation to cover screening, diagnoses and treatment of all sexually transmitted infections under the ACA.

"This bulletin directed insurers to take the necessary steps to assure that they provide clinically appropriate coverage of periodic STI screening, as well as diagnostic testing and treatment, and that their medical management practices comply with the law," Soller stated.

Lara also issued a bulletin the same day reminding companies that they have to provide PrEP without cost sharing as preventative care, and a notice that PrEP use "cannot be used as a justification to deny life, disability or long-term care insurance coverage or charge higher premiums for that coverage" under California law, Soller stated.

In 2019 Lara issued a notice to insurers that they could not deny coverage to users of PrEP, as the B.A.R. reported at the time.

Currently, Lara's office is co-sponsoring two pieces of legislation relating to PrEP. Assembly Bill 1649, by gay Assemblymember Rick Chavez Zbur (D-West Hollywood/Santa Monica), would require insurance policies and health plans to cover sexually transmitted infection screenings without cost sharing, and make it part of state law that preventative care has to be covered without cost sharing.

Senate Bill 427, by Senator Anthony Portantino (D-Glendale), would require insurance companies to cover both PrEP and PEP, or post-exposure prophylaxis, without cost sharing, "including by grandfathered health insurance policies and health plans that are not otherwise required to cover preventive care under the ACA and state law," Soller stated.

Currently, one million Californians who are in these grandfathered plans pay out of pocket for PrEP, according to Soller.

"We are currently reviewing the recommendations proposed by the consumer representatives and are looking for additional ways to incorporate them into our processes," Soller added.

Lara, the Golden State's first gay elected statewide officer, asked the federal government last year to lift restrictions on gay and bisexual men donating blood.

LGBTQ Agenda is an online column that appears weekly, but will be on break for the Labor Day holiday, returning September 12. Got a tip on queer news? Contact John Ferrannini at [email protected]

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