[Congressional Bills 119th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5127 Introduced in House (IH)]
<DOC>
119th CONGRESS
1st Session
H. R. 5127
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.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
September 4, 2025
Ms. Waters (for herself, Mr. Garcia of California, Mr. Nadler, Ms.
Norton, Mr. Thompson of Mississippi, Mr. Krishnamoorthi, Ms. Garcia of
Texas, Ms. Velazquez, Ms. Sewell, Mr. Carson, Mr. Jackson of Illinois,
Ms. Titus, Mr. Johnson of Georgia, Mrs. McIver, Mrs. Beatty, Mr.
Cleaver, Mr. Cohen, Ms. Wilson of Florida, Ms. Simon, Mr. Thanedar, Mr.
Mullin, Mrs. Ramirez, Ms. Barragan, Mrs. Watson Coleman, Ms. Tlaib, Ms.
Clarke of New York, and Ms. Williams of Georgia) introduced the
following bill; which was referred to the Committee on Energy and
Commerce, and in addition to the Committees on Ways and Means, and
Oversight and Government Reform, for a period to be subsequently
determined by the Speaker, in each case for consideration of such
provisions as fall within the jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
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.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``PrEP and PEP are Prevention Act''.
SEC. 2. NO-COST COVERAGE OF HIV PREVENTION SERVICES.
(a) Private Insurance.--
(1) In general.--Section 2713(a) of the Public Health
Service Act (42 U.S.C. 300gg-13(a)) is amended--
(A) in paragraph (2), by striking ``; and'' and
inserting a semicolon;
(B) in paragraph (3), by striking the period and
inserting a semicolon;
(C) in paragraph (4), by striking the period and
inserting a semicolon;
(D) in paragraph (5), by striking the period and
inserting ``; and''; and
(E) by adding at the end the following:
``(6) any prescription drug approved by the Food and Drug
Administration for the prevention of HIV (other than a drug
subject to preauthorization requirements consistent with
section 2729A), including any such drug approved for use as
pre-exposure prophylaxis (commonly referred to as `PrEP') or as
post-exposure prophylaxis (commonly referred to as `PEP'),
administrative fees for such drugs, laboratory and other
diagnostic procedures associated with the use of such drugs,
counseling with respect to HIV prevention (including HIV risk
assessment, HIV risk reduction, and medication adherence), and
clinical follow up and monitoring, including any related
services recommended in current United States Public Health
Service clinical practice guidelines, without limitation.''.
(2) Prohibition on preauthorization requirements.--Subpart
II of part A of title XXVII of the Public Health Service Act
(42 U.S.C. 300gg-11 et seq.) is amended by adding at the end
the following:
``SEC. 2729A. PROHIBITION ON PREAUTHORIZATION REQUIREMENTS WITH RESPECT
TO CERTAIN SERVICES.
``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)(6), 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.''.
(3) Effective date.--The amendments made by this subsection
shall apply beginning with respect to the first plan year
beginning after the date of enactment of this section.
(b) Medicare.--
(1) Coverage of hiv prevention services under part b.--
(A) Coverage.--
(i) In general.--Section 1861(s)(2) of the
Social Security Act (42 U.S.C. 1395x(s)(2)) is
amended--
(I) in subparagraph (JJ), by
inserting ``and'' at the end; and
(II) by adding at the end the
following new subparagraph:
``(KK) HIV prevention services (as defined in subsection
(nnn));''.
(ii) Definition.--Section 1861 of the
Social Security Act (42 U.S.C. 1395x) is
amended by adding at the end the following new
subsection:
``(nnn) HIV Prevention Services.--The term `HIV prevention
services' means--
``(1) drugs or biologicals approved by the Food and Drug
Administration for the prevention of HIV, including any such
drug or biological approved for use as pre-exposure prophylaxis
(commonly referred to as `PrEP') or as post-exposure
prophylaxis (commonly referred to as `PEP');
``(2) administrative fees for such drugs and biologicals;
``(3) laboratory and other diagnostic procedures associated
with the use of such drugs and biologicals;
``(4) counseling with respect to HIV prevention, including
HIV risk assessment, HIV risk reduction, and medication
adherence; and
``(5) clinical follow up and monitoring, including any
related services recommended in current United States Public
Health Service clinical practice guidelines, without
limitation.''.
(B) Elimination of coinsurance.--Section 1833(a)(1)
of the Social Security Act (42 U.S.C. 1395l(a)(1)) is
amended--
(i) by striking ``and (HH)'' and inserting
``(HH)''; and
(ii) by inserting before the semicolon at
the end the following: ``, and (II) with
respect to HIV prevention services (as defined
in section 1861(nnn)), 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)''.
(C) Exemption from part b deductible.--The first
sentence of section 1833(b) of the Social Security Act
(42 U.S.C. 1395l(b)) is amended--
(i) by striking ``, and (13)'' and
inserting ``(13)''; and
(ii) 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(nnn)(1)).''.
(D) Effective date.--The amendments made by this
paragraph shall apply to items and services furnished
on or after January 1 of the first calendar year
beginning after the date of enactment of this section.
(2) Elimination of cost-sharing for drugs for the
prevention of hiv under part d.--
(A) In general.--Section 1860D-2 of the Social
Security Act (42 U.S.C. 1395w-102(b)) is amended--
(i) in subsection (b)--
(I) in paragraph (1)(A), by
striking ``and (9)'' and inserting ``,
(9), and (10)'';
(II) in paragraph (2)--
(aa) in subparagraph (A),
by striking ``and (9)'' and
inserting ``, (9), and (10)'';
(bb) in subparagraph
(C)(i), in the matter preceding
subclause (I), by striking
``and (9)'' and inserting
``(9), and (10)''; and
(cc) in subparagraph
(D)(i), in the matter preceding
subclause (I), by striking
``and (9)'' and inserting
``(9), and (10)'';
(III) in paragraph (3)(A), in the
matter preceding clause (i), by
striking ``and (9)'' and inserting
``(9), and (10)'';
(IV) in paragraph (4)(A)(i), by
striking ``and (9)'' and inserting ``,
(9), and (10)''; and
(V) by adding at the end the
following new paragraph:
``(10) Elimination of cost-sharing for drugs for the
prevention of hiv.--With respect to a covered part D drug that
is for the prevention of HIV--
``(A) the deductible under paragraph (1) shall not
apply; and
``(B) there shall be no coinsurance or other cost-
sharing under this part with respect to such drug.'';
and
(ii) in subsection (c), by adding at the
end the following new paragraph:
``(7) Treatment of cost-sharing for drugs for the
prevention of hiv.--The coverage is provided in accordance with
subsection (b)(10).''.
(B) Conforming amendments to cost-sharing for low-
income individuals.--Section 1860D-14(a) of the Social
Security Act (42 U.S.C. 1395w-114(a)) is amended--
(i) in paragraph (1)(D), in each of clauses
(ii) and (iii), by striking ``paragraph (6)''
and inserting ``paragraphs (6) and (7)'';
(ii) in paragraph (2)--
(I) in subparagraph (B), by
striking ``and (9)'' and inserting ``,
(9), and (10)'';
(II) in subparagraph (D), by
striking ``paragraph (6)'' and
inserting ``paragraphs (6) and (7)'';
and
(III) in subparagraph (E), by
striking ``paragraph (6)'' and
inserting ``paragraphs (6) and (7)'';
and
(iii) by adding at the end the following
new paragraph:
``(7) No application of cost-sharing or deductible for
drugs for the prevention of hiv.--With respect to a covered
part D drug that is for the prevention of HIV--
``(A) the deductible under section 1860D-2(b)(1)
shall not apply; and
``(B) there shall be no cost-sharing under this
section with respect to such drug.''.
(C) Effective date.--The amendments made by this
paragraph shall apply beginning with respect to the
first plan year beginning after the date of enactment
of this section.
(c) Medicaid and CHIP.--
(1) Medicaid.--
(A) In general.--Section 1905 of the Social
Security Act (42 U.S.C. 1396d) is amended--
(i) in subsection (a)(4)--
(I) by striking ``; and (D)'' and
inserting ``; (D)'';
(II) by striking ``; and (E)'' and
inserting ``; (E)'';
(III) by striking ``; and (F)'' and
inserting ``; (F)''; and
(IV) by striking the semicolon at
the end and inserting ``; and (G) HIV
prevention services;''; and
(ii) by adding at the end the following new
subsection:
``(ll) HIV Prevention Services.--For purposes of subsection
(a)(4)(G), the term `HIV prevention services' means prescription drugs
approved by the Food and Drug Administration for the prevention of HIV,
including any such drug approved for use as pre-exposure prophylaxis
(commonly referred to as `PrEP') or as post-exposure prophylaxis
(commonly referred to as `PEP'), administrative fees for such drugs,
laboratory and other diagnostic procedures associated with the use of
such drugs, counseling with respect to HIV prevention (including HIV
risk assessment, HIV risk reduction, and medication adherence), and
clinical follow up and monitoring, including any related services
recommended in current United States Public Health Service clinical
practice guidelines, without limitation.''.
(B) No cost-sharing.--Title XIX of the Social
Security Act (42 U.S.C. 1396 et seq.) is amended--
(i) 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
(ii) in section 1916A(b)(3)(B), by adding
at the end the following new clause:
``(xv) HIV prevention services described in
section 1905(a)(4)(G).''.
(C) Inclusion in benchmark coverage.--Section
1937(b)(7) of the Social Security Act (42 U.S.C. 1396u-
7(b)(7)) is amended--
(i) in the paragraph header, by inserting
``and hiv prevention services'' after
``supplies''; and
(ii) 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''.
(2) CHIP.--
(A) In general.--Section 2103 of the Social
Security Act (42 U.S.C. 1397cc), as amended by section
11405(b)(1) of Public Law 117-169, is amended--
(i) in subsection (a), by striking ``and
(8)'' and inserting ``(8), and (13)''; and
(ii) in subsection (c), by adding at the
end the following new paragraph:
``(13) HIV prevention services.--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)).''.
(B) No cost-sharing.--Section 2103(e)(2) of the
Social Security Act (42 U.S.C. 1397cc(e)(2)) is amended
by inserting ``HIV prevention services described in
subsection (c)(13),'' before ``or for pregnancy-related
assistance''.
(3) Effective date.--
(A) In general.--Subject to subparagraph (B), the
amendments made by this subsection shall take effect on
January 1 of the first calendar year beginning after
the date of enactment of this section.
(B) Delay permitted if state legislation
required.--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 the 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.
(d) Federal Employees Health Benefits Program.--
(1) In general.--Section 8904 of title 5, United States
Code, is amended by adding at the end the following:
``(c) 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
for the prevention of HIV, including any such drug approved for use as
pre-exposure prophylaxis (commonly referred to as `PrEP') or as post-
exposure prophylaxis (commonly referred to as `PEP'), administrative
fees for such drugs, laboratory and other diagnostic procedures
associated with the use of such drugs, counseling with respect to HIV
prevention (including HIV risk assessment, HIV risk reduction, and
medication adherence), and clinical follow up and monitoring, including
any related services recommended in current United States Public Health
Service clinical practice guidelines, without limitation.''.
(2) Effective date.--The amendments made by this subsection
shall apply beginning with respect to the first plan year
beginning after the date of enactment of this section.
<all>