Sponsors (36)
The bill greatly expands no‑cost access to FDA‑approved HIV prevention across insurance types—improving prevention and reducing out‑of‑pocket costs—while creating meaningful cost pressures on insurers, taxpayers, and state Medicaid programs that could prompt offsetting plan designs, fiscal tradeoffs, or implementation burdens.
People at risk of HIV across private insurance, Medicare, and Medicaid/CHIP gain no‑cost access to all FDA‑approved HIV prevention drugs (PrEP/PEP) and associated labs, counseling, and follow‑up, increasing prevention uptake and reducing infections.
Medicare beneficiaries face eliminated coinsurance and deductibles for covered HIV prevention services and drugs (Part B and Part D), directly lowering out‑of‑pocket costs for seniors.
Medicaid and CHIP enrollees—including low‑income children and pregnant people—must have HIV prevention services covered with no cost‑sharing, expanding access for traditionally underserved populations.
Insurers and taxpayers will bear higher drug and service costs from eliminating cost‑sharing, which could translate into higher premiums, increased federal/state spending, or greater taxpayer burden.
Private insurers may respond to higher costs by narrowing formularies, imposing utilization management on non‑equivalent drugs, or raising premiums, which could reduce access or choice for some patients.
State Medicaid programs will face increased program costs and implementation requirements, pressuring state budgets and possibly forcing tradeoffs or program changes.
Based on analysis of 2 sections of legislative text.
Mandates no‑cost coverage and limits prior authorization for FDA‑approved HIV prevention drugs and services in private plans, and creates a Medicare Part B HIV prevention benefit with no coinsurance or Part B deductible.
Official title: To amend title XXVII of the Public Health Service Act, titles XVIII, XIX, and XXI of the Social Security Act, and title 5, United States Code, to require no-cost coverage of certain HIV prevention services.
Introduced September 4, 2025 by Maxine Waters · Last progress September 4, 2025
Requires private group and individual health plans to cover, without cost-sharing, FDA‑approved HIV prevention drugs (including PrEP and PEP) and related services (labs, counseling, monitoring) consistent with clinical guidelines, and bans most prior authorization for those services. Also creates a Medicare Part B "HIV prevention services" benefit that covers FDA‑approved prevention drugs, associated services, removes coinsurance and the Part B deductible for those services, and sets Medicare payment at 100% of the applicable amount.