Sec. 3. Coverage requirements

2,682 words·~12 min read·/bill/119/hr/7853/ih/section-3

A research copy — for the controlling text, always check the official state or federal source. Not legal advice.

Section 2713(a) of the Public Health Service Act ( 42 U.S.C. 300gg–13(a) ) is amended— in paragraph (2), by striking ; and and inserting a semicolon; in paragraph (3), by striking the period and inserting a semicolon; in paragraph (4), by striking the period and inserting ; and ; by striking paragraph (5); by adding at the end the following: 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 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. . 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: Section 2713(a)(5) (relating to coverage without cost-sharing for prescription drugs for the prevention of HIV). .

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: 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. .

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: 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. .

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. . Chapter 100 of the Internal Revenue Code of 1986 is amended by adding at the end of subchapter B the following: 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. .

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. . Section 8904 of title 5, United States Code, is amended by adding at the end the following: 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. .

Section 1905 of the Social Security Act ( 42 U.S.C. 1396d ) is amended by— in subsection (a)(4), by striking the semicolon at the end and inserting ; and

(G)HIV prevention services; ; and by adding at the end the following new subsection: 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. . Title XIX of the Social Security Act ( 42 U.S.C. 1396 et seq. ) is amended— 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 in section 1916A(b)(3)(B), by adding at the end the following new clause: HIV prevention services described in section 1905(a)(4)(G). . Section 1937(b)(7) of the Social Security Act ( 42 U.S.C. 1396u–7(b)(7) ) is amended— in the paragraph heading, by inserting after and HIV prevention services ; and supplies 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 . Section 2103 of the Social Security Act ( 42 U.S.C. 1397cc ) is amended— in subsection (a), in the matter preceding paragraph (1), by striking and

(8)and inserting (8), and

(13); and in subsection (c), by adding at the end the following new paragraph: 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)). . Section 2103(e)(2) of the Social Security Act ( 42 U.S.C. 1397cc(e)(2) ) is amended— in the paragraph heading, by inserting after HIV prevention services, ; and treatment, by inserting HIV prevention services described in subsection (c)(13), before or for pregnancy-related assistance . Subject to subparagraph (B), the amendments made by subsection

(c)and this subsection shall take effect on January 1, 2027. 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. Section 1861(s)(2) of the Social Security Act ( 42 U.S.C. 1395x(s)(2) ) is amended— in subparagraph (JJ), by striking and at the end; in subparagraph (KK), by inserting and at the end; and by adding at the end the following new subparagraph: HIV prevention services (as defined in subsection (ooo)); . Section 1861 of the Social Security Act ( 42 U.S.C. 1395x ) is amended by adding at the end the following new subsection: The term HIV prevention services means— drugs or biologicals approved by the Food and Drug Administration 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. . Section 1833(a)(1) of the Social Security Act ( 42 U.S.C. 1395l(a)(1) ) is amended— by striking and

(HH)and inserting

(HH); and 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). The first sentence of section 1833(b) of the Social Security Act ( 42 U.S.C. 1395l(b) ) is amended— by striking , and

(13)and inserting

(13); and 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)). . The amendments made by this paragraph shall apply to items and services furnished on or after January 1, 2027. Section 1860D–2 of the Social Security Act ( 42 U.S.C. 1395w–102 ) is amended— in subsection (b)— in paragraph (1)(A), by striking and

(9)and inserting , (9), and

(10); in paragraph (2)— in subparagraph (A), by striking and

(9)and inserting , (9), and

(10); in subparagraph (C)(i), in the matter preceding subclause (I), by striking and

(9)and inserting (9), and

(10); and in subparagraph (D)(i), in the matter preceding subclause (I), by striking and

(9)and inserting (9), and

(10); in paragraph (3)(A), in the matter preceding clause (i), by striking and

(9)and inserting (9), and

(10); in paragraph (4)(A)(i), by striking and

(9)and inserting , (9), and

(10); and by adding at the end the following new paragraph: 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— the deductible under paragraph

(1)shall not apply; and there shall be no coinsurance or other cost-sharing under this part with respect to such drug. ; and in subsection (c), by adding at the end the following new paragraph: The coverage is provided in accordance with subsection (b)(10). . Section 1860D–14(a) of the Social Security Act ( 42 U.S.C. 1395w–114(a) ) is amended— in paragraph (1)(D), in each of clauses

(ii)and (iii), by striking paragraph

(6)and inserting paragraphs

(6)and

(7); in paragraph (2)— in subparagraph (B), by striking and

(9)and inserting , (9), and

(10); in subparagraph (D), by striking paragraph

(6)and inserting paragraphs

(6)and

(7); and in subparagraph (E), by striking paragraph

(6)and inserting paragraphs

(6)and

(7); and by adding at the end the following new paragraph: 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— the deductible under section 1860D–2(b)(1) shall not apply; and there shall be no cost-sharing under this section with respect to such drug. . Section 1722A(a) of title 38, United States Code, is amended by adding at the end the following new paragraph: Paragraph

(1)does not apply to a medication for the prevention of HIV. . Section 1710 of such title is amended— in subsection (f)— by redesignating paragraph

(5)as paragraph (6); and by inserting after paragraph

(4)the following new paragraph (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 in subsection (g)(3), by adding at the end the following new subparagraph: 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. . Section 1701(9) of such title is amended— in subparagraph (K), by striking ; and and inserting a semicolon; by redesignating subparagraph

(L)as subparagraph (M); and by inserting after subparagraph

(K)the following new subparagraph (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 . Chapter 55 of title 10, United States Code, is amended by inserting after section 1074o the following new section: 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. 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. 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. . 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. . Title II of the Indian Health Care Improvement Act is amended by inserting after section 223 ( 25 U.S.C. 1621v ) the following: 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. There are authorized to be appropriated such sums as are necessary to carry out this section. . 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.

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