H.R. 5127

119 HR 5127 IH: PrEP and PEP are Prevention Act
 U.S. House of Representatives
 2025-09-04
 text/xml
 EN
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 I  119th CONGRESS  1st Session  H. R. 5127  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. Velázquez ,  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. Barragán ,  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.
1.
Short title
This Act may be cited as the   PrEP and PEP are Prevention Act  .
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:
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.