Sponsors (35)
Introduced September 4, 2025 by Maxine Waters · Last progress September 4, 2025
The bill greatly expands no‑cost access to FDA‑approved HIV prevention across private insurance, Medicare, and Medicaid/CHIP—reducing financial and administrative barriers to prevention—while increasing public/private spending, creating fiscal and implementation pressures, and risking insurer responses that could limit drug choice or clinical flexibility.
People at risk of HIV who have private insurance, Medicare, or Medicaid/CHIP gain no‑cost coverage for all FDA‑approved HIV prevention drugs (PrEP/PEP) and related labs, counseling, and follow‑up, removing financial barriers to prevention care.
Medicare beneficiaries specifically face no coinsurance or deductible for Part B HIV prevention services and have the Part D deductible and cost‑sharing eliminated for covered HIV prevention drugs, substantially lowering senior out‑of‑pocket costs for prevention.
Medicaid and CHIP enrollees, including low‑income children and pregnant women, must receive HIV prevention services with no cost‑sharing, expanding access for economically vulnerable populations.
Insurers and taxpayers will bear higher drug and service costs from eliminating cost‑sharing, which could increase insurance premiums, raise federal/state spending, or shift costs elsewhere.
Private insurers may respond by narrowing formularies, imposing utilization management on non‑equivalent drugs, or raising premiums to offset costs, which could limit choice or access in practice.
State Medicaid programs must implement coverage changes and may face increased program costs, pressuring state budgets and potentially requiring program adjustments.
Based on analysis of 2 sections of legislative text.
Requires private plans to cover FDA‑approved HIV prevention drugs and related services without cost‑sharing, limits prior authorization, and makes comparable Medicare Part B coverage changes.
Requires private group and individual health plans to cover, without cost‑sharing, any FDA‑approved drug for HIV prevention (including PrEP and PEP) and related services like lab tests, counseling, and clinical follow‑up consistent with current federal prevention guidelines. Bars most prior‑authorization requirements for those services (with a narrow exception) and makes comparable coverage and cost‑sharing changes in Medicare Part B so beneficiaries pay no coinsurance or deductible for covered HIV prevention services. The private‑insurance changes apply to plan years beginning after enactment; Medicare payment and benefit rules are amended to classify and define “HIV prevention services,” adjust Part B payment to 100% for those services, and exempt them from the Part B deductible (exact Medicare effective timing is not fully specified in the provided text).