Increasing access to HIV services is paramount to fighting back against the disease’s spread in the US. Yet, despite this, fewer than one in five people living with HIV has private insurance, and nearly 30% do not have any coverage, according to the CDC.

Pharmaceutical companies may provide avenues for the most vulnerable groups to gain access to medications free of charge – but the eligibility criteria are usually stringent.

Given the high costs and lack of healthcare access, many ask, “Are HIV services covered under the ACA?”

Without treatment, HIV is a serious and deadly condition; only through retroviral drugs or pre-exposure prophylaxis (PrEP) can HIV levels be successfully reduced. For thousands, if not millions, of Americans, the ACA, therefore, represents the best hope of gaining access to HIV services.

The Affordable Care Act (ACA) (also known as Obamacare) was enacted in March 2010 to reduce the costs of medical care for millions of Americas. For households whose income was between 100% to 400% of the federal poverty level, subsidies are provided; Medicaid is substantially expanded; and support for innovative medical care delivery methods is designed to lower overall medical costs.

Brought in by President Obama, the landmark piece of legislation extended coverage to millions of uninsured Americans and prevented corporations from charging more due to pre-existing conditions or gender. These changes had a significant impact on the provision of HIV services.

In short, yes. HIV services are specifically accounted for under the ACA. However, the ACA is a complicated piece of legislation – different aspects affect HIV and AIDs patients in different ways. Here we’ll cover some of the major benefits:

Under the ACA, insurers can no longer deny coverage to children living with HIV or AIDS. Where before the system locked out those living with HIV or AIDs, the Pre-existing Condition Insurance Plan helped more than 90,000 people – some of whom were living with HIV or AIDs – to access healthcare, saving lives.

In addition, for 105 million Americans, the lifetime dollar limit on essential health benefits was rescinded, improving access to insurance for people living with HIV or AIDS. The ACA also closed the so-called “donut hole” for Medicare Part D prescription drug benefits. By doing so, it gave HIV and AIDS patients peace of mind, knowing they’ll be able to afford their medications.

According to the CDC, “beneficiaries receive a 50% discount on covered brand-name drugs while they are in the “donut hole,” a considerable savings for people taking costly HIV/AIDS drugs.”

In 2020, it was announced that the ACA employer-sponsored health plans would cover HIV specialty drugs by 100% following June 19, 2020. The announcement came after the United States Preventive Services Task Force (USPSTF) recommendations for health plans to cover pre-exposure prophylaxis and effective antiretroviral therapies.

This change primarily affected HIV specialty drugs like Pruvada and Descovy.

The ACA already ensured new health insurance plans must cover certain recommended preventative services, e.g., HIV testing, for everyone aged 15 to 65 years old without additional cost-sharing. With 13% of people with HIV in the US unaware of their status, it was hoped this change might improve access to care and treatment.

In the USPSTF report, services were given an “A” or “B” recommendation depending on their importance. An “A” recommendation was given to clinicians to offer PrEP with antiretroviral therapy to persons at high risk of HIV. As per the APA, these plans without cost-sharing began to take effect in June 2020.

The plan permits sponsors to cover generic versions of PrEP (e.g., for Truvada) without cost-sharing and charge cost sharing for the brand version. Additional tests and services needed as part of PrEP and other treatments are also included in the coverage, e.g., HIV testing, Hepatitis B and C testing, kidney function tests, pregnancy tests, screening and counseling for STIs, and adherence counseling.

For patients, seeking HIV or AIDS treatment through the Affordable Care Act has never been easier. Since the act was passed, thousands of patients have benefited from its provisions. The groundbreaking legislation paved the way for affordable HIV treatments, from more affordable medication to reduced discrimination.

There are some concerns, however, regarding novel treatments. For example, Apretude, the world’s first injectable PrEP, is not yet covered under the ADA – it is left to the insurer’s discretion.

Nevertheless, since its implementation, you can now gain access to the most important HIV services. For more information, please speak to our physician about HIV services and the ACA.