What to Know About New Law Ensuring Access to Emergency HIV Post Exposure Prevention

A new Washington state law (SB 6127) meant to ensure patients have access to emergency HIV post-exposure prophylaxis (PEP) drugs, takes effect January 1, 2025. It requires hospitals to dispense a 28-day supply of HIV PEP drugs to patients upon discharge from the emergency department. As part of the legislation, there are new rules on cost-sharing, prior authorization, and reimbursement that will impact your billing with LifeWise.

Here’s what you need to know:

• This law impacts non-grandfathered health plans issued or renewed on or after January 1, 2025.
• This bill affects the medical benefit, not the prescription (RX) benefit.
• Plans can’t impose cost-sharing on the member or require prior authorization for at least one regimen recommended by the CDC for HIV post-exposure prophylaxis when covered by this new law.
• For members with a plan offering a Health Savings Account (HSA), cost-sharing must be set at the minimum level necessary to maintain tax-exempt status.
• Plans are required to reimburse a hospital that bills for HIV post-exposure prophylaxis drugs dispensed or delivered to a patient in the emergency department for take-home use.
• Plans are required to reimburse for the drugs as a separate reimbursable expense. This reimbursable expense is separate from any bundled payment for emergency department services.

Here’s what you need to do:

• To ensure accurate reimbursement, the dispensed HIV post-exposure drugs or therapies must be billed as a separate line item with a take home drug revenue code, a diagnosis code reflecting the possible exposure to HIV, the HCPCS code appropriate for the post-exposure drug or an unlisted code specific to an oral specific drug, and valid National Drug Codes (NDCs).
• If the hospital is repackaging post-exposure drugs, include any component NDCs as applicable.
• If you make a billing error, a corrected claim is required for reconsideration.

for more information on billing NDC codes on an outpatient facility claim (UB-04/CMS-1450 paper or 837I electronic), visit our payment policies and review the policy “National Drug Code (NDC) Billing Guidelines, Outpatient Facility Claims (cmi_171641)” or contact your network representative.