June 13, 2022
Area(s) of Interest: Payor Issues and Reimbursement
The California Department of Insurance (CDI) is warning health insurers that refusing to cover necessary treatments and limiting coverage for sexually transmitted infection (STI) screening to one per year is unlawful.
At a pivotal time when the Centers for Disease Control and Prevention (CDC) reports an alarming increase in STIs nationwide, the CDI is finding that several insurers are shifting the cost of preventative screenings, diagnoses and treatments to patients and creating unnecessary and unlawful obstacles to preventing the spread of HIV, syphilis, chlamydia, hepatitis, and other STIs. .
The Affordable Care Act (ACA) and California law both prohibit limiting STI screenings of persons who are at increased risk of infection.
Additionally, California law requires most health insurers to cover screening, diagnostic testing and treatment for any health condition according to current, generally accepted standards of care. Consequently, insurers must cover clinically recommended periodic STI screening, even when it is not required preventive care under the ACA.
The CDI bulletin explains that existing federal and state law requires insurance companies to:
- Cover STI screening, diagnosis and treatment in accordance with current, generally accepted standards of care.
- Cover STI screenings that are within the scope of the ACA without patient cost sharing.
- Cover clinically recommended STI screenings that are not defined as preventive care under the ACA.
- Not impose coverage limits on STI screenings that conflict with evidence-based clinical recommendations on screening intervals.
- In pharmacy benefits, cover prescription drugs that are medically necessary to treat STIs, including direct-acting antivirals for curing hepatitis C.
- Cover home self-collection test kits and laboratory costs for detecting STIs.
- Cover combination antigen/antibody HIV self-tests, including combination rapid fingerstick tests, without a deductible from or other cost sharing on patients.
CDI informed insurers that they must immediately eliminate any impermissible limits that they have arbitrarily imposed on coverage of clinically recommended STI screening, testing or treatment.
The growing STI crisis in California and across the county has been exacerbated by the COVID-19 pandemic, disproportionately affecting youth, people of color, and gay, bisexual, and transgender people .