Insurance Coverage & Cost-Effectiveness


PEHTI offers guidance and technical support on health insurance coverage and/or reimbursement/billing (if fee-for-service) for routine HIV screening in healthcare settings (i.e. incl. managed care documentation of fulfillment of standard-of-care for preventive services and billing codes for services provided under fee-for-service health insurance). The following reference documents provide guidance:

  • USPSTF Grade A rating for opt-out HIV screening as a basis for inclusion of opt-out HIV screening in the managed care preventive care package or reimbursement/billing in the context of fee-for-service coverage.
  • Required coverage of Preventive Health Services (with no coinsurance or deductibles) including HIV screening under the Affordable Care Act (Sec. 2713, Patient Protection and Affordable Care Act, HR 3590) – Stipulates that a group health plan and a health insurance issuer offering group or individual health insurance coverage shall provide coverage for and shall not impose any cost sharing  requirements (i.e. no coinsurance or deductible) for: (1) evidence based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the US Preventive Services Task Force (USPSTF); (2) immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the CDC with respect to the individual involved;
    • In addition, the statute specifically removes barriers to preventive services in Medicare (Sec. 4104, Patient Protection and Affordable Care Act, HR 3590) – Waives coinsurance requirements for most preventive services, and services for which no coinsurance or deductible would be required are the personalized prevention plan services, an initial preventive physical examination and any covered preventive service if it is recommended with a grade of A or B by the USPSTF.
    • ALL MANAGED CARE COVERAGE – IMPORTANT TO NOTE: As any managed care health insurance plan (group and individual plans) is now required by law to cover USPSTF Grade A rated preventive services such as opt-out/routine HIV screening with no coinsurance or deductible, it is important for providers to note that the 2013 USPSTF Grade A rating places HIV screening firmly within the scope of preventive services that are required to be covered in capitated services rendered under any  managed care coverage. Notwithstanding, PEHTI recognizes the major transitions underway in the healthcare coverage landscape and other attendant issues, and will continue to work with partners towards improving healthcare providers’ understanding of the statutory requirements/implications of Sec. 2713, Patient Protection and Affordable Care Act, HR 3590 on preventive services such as opt-out HIV screening which are to be offered by healthcare providers as a standard of care.
  • Coding guide for routine HIV testing in health care settings (AMA/AAHIVMA)



To appropriately direct opt-out HIV screening across various settings, it is necessary to monitor services, expenditure/health coverage costs, and evaluate outcomes of services including assessment of the cost-effectiveness and cost-benefit thereof.