Commissioner Lara bans insurance companies from limiting access to life-saving screenings and treatment

News: 2022 Press Release

LOS ANGELES – Acting to protect the public health of California consumers, Insurance Commissioner Ricardo Lara today advised health insurers that arbitrarily refusing to cover necessary treatments and limiting coverage for periodic sexually transmitted infections screening to one per year is unlawful.

At a pivotal time when the U.S. Centers for Disease Control and Prevention (CDC) is reporting alarming increases in STIs nationwide and in California, the California Department of Insurance is finding that several insurers are shifting the costs of preventive screenings, diagnosis, and treatments onto consumers, which only creates further barriers to preventing the spread of HIV, syphilis, chlamydia, hepatitis, and other sexually transmitted infections (STIs), especially during the continued COVID-19 pandemic. The federal Affordable Care Act (ACA) and California law bar the practice of limiting periodic STI screenings of persons who are at increased risk of infection in ways that deprive consumers of equitable coverage of clinically recommended preventive care.

Additionally, California law provides that most health insurers must cover screening, diagnostic testing, and treatment for any health condition according to current, generally accepted standards of care. Consequently, insurers must cover clinically recommended periodic STI screening even when it is not required preventive care under the ACA.

“Personal health is public health. After we learned from consumers that they were being denied care, we moved to act,” said Commissioner Lara, who continues to be at the forefront of expanding health care access for all California residents. “My top priority is protecting consumers and holding insurance companies accountable.”

Commissioner Lara’s Bulletin explains that existing federal and state law requires insurance companies to:

• Cover STI screening, diagnosis, and treatment in accordance with current, generally accepted standards of care.
• Cover STI screenings that are within the scope of the ACA without patient cost sharing.
• Cover clinically recommended STI screenings that are not defined as preventive care under the ACA.
• Not impose coverage limits on STI screenings that conflict with evidence-based clinical recommendations on screening intervals.
• In pharmacy benefits, cover prescription drugs that are medically necessary to treat STIs, including direct-acting antivirals for curing hepatitis C.
• Cover home self-collection test kits and laboratory costs for detecting STIs.
• Cover combination antigen/antibody HIV self-tests, including combination rapid fingerstick tests, without a deductible from or other cost sharing on patients.

The Commissioner’s Bulletin further states that insurance companies must understand that the law prohibits them from limiting benefits in a clinically inappropriate manner and that they must immediately eliminate any impermissible limits (like quantity limits) that they arbitrarily impose on coverage of clinically recommended STI screening, testing, or treatment.

“The Center welcomes this clear guidance from Commissioner Lara holding insurers accountable to comply with existing regulations,” said Dr. Ward Carpenter, Co-Director of Health Services for the Los Angeles LGBT Center. “As one of the largest providers of healthcare for LGBTQIA people, we see too many patients being inappropriately denied coverage for STI care they are entitled to receive. And we see the burden these denials cause, from delayed treatment to worsening health. We also know there are multiple additional transmissions when a person with an STI is unable to access timely and appropriate care. Ultimately we all pay the price for these denials in higher healthcare costs and more lives impacted. We must have free, easy access to the full scope of testing and treatment if we are to seriously combat the soaring STI rates in our community. The Center applauds Commissioner Lara for ensuring that the health of our community never takes a back seat to the profits of an insurance company.”

The growing STI crisis affects all communities across the state, with youth, people of color, and gay, bisexual, and transgender people disproportionately impacted. Statewide data indicate over half of all STIs in the state are experienced among California’s young people ages 15 to 24 years old. African Americans are 500% more likely to contract gonorrhea and chlamydia than their white counterparts. In addition, the continued COVID-19 pandemic has only further exacerbated the STI crisis, with populations disproportionately affected by STIs being particularly vulnerable to access to equitable and culturally competent health care, among other consequences.

Over the past decade, California has experienced an alarming increase in cases of syphilis and congenital syphilis. There were 28,846 reported cases of syphilis in 2019, a 349% increase since 2009. Cases of congenital syphilis, which occur when syphilis is transmitted from a pregnant person to their child during pregnancy, increased 631% over the same period. While gay and bisexual men account for most new syphilis cases, the largest increases have been among women. From 2009-2019, the total number of early syphilis cases increased 1,139% among women compared to 290% among men. Increases in the rate of congenital syphilis among women of reproductive age have paralleled steep increases in the rate of congenital syphilis. In 2019, there were 446 reported cases of congenital syphilis in California – the highest number of cases since 1993. Syphilis and congenital syphilis rates are roughly three times higher among Black Californians compared to their white counterparts.

“The latest data from the CDC reaffirm what we have known for quite some time – the U.S. is in the midst of an out-of-control STI epidemic that has only worsened over the course of the pandemic,” said APLA Health Chief Executive Officer Craig E. Thompson. “If we are to get a handle on this crisis, all Californians need access to regular, convenient, and free or low cost STI testing and treatment. Insurance companies are essential partners in this fight and they must be held accountable for providing unimpeded access to the full range of STI services. Today’s bulletin from Commissioner Lara is an important step toward ending the state’s growing STI epidemic and improving the sexual health of LGBTQ+, BIPOC, and other impacted communities."

California continues to take aggressive approaches to expand access to comprehensive health coverage, including with laws that Commissioner Lara sponsored last year that require insurers to cover basic benefits in large employer health insurance and to allow dependent parents to be added to their adult children’s health insurance policy or health care plan.

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Media Notes:

• Bulletin 2022-3: Coverage Limits on Screening Diagnosis and Treatment of Sexually Transmitted Infections
• California Department of Public Health. STDs in California: 2019 Snapshot. Available at: https://www.cdph.ca.gov/Programs/CID/DCDC/CDPH%20Document%20Library/2019-STD-Snapshot.pdf
• CDPH on Congenital Syphilis, available at: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/CongenitalSyphilis.aspx
• CDPH’s Sexually Transmitted Diseases Control Branch, available at: https://www.cdph.ca.gov/Programs/CID/DCDC/Pages/STD.aspx