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HMOs ordered to provide medical coverage to people with HIV… with limitations

HMOs are expected to provide coverage to PLHIVs under the following conditions: he/she is undergoing proper medical treatment; he/she has a favorable risk profile; and the results of the medical examinations required by the HMO are within normal limits.

Photo by Bill Oxford from Unsplash.com

The Insurance Commission (IC) has ordered health maintenance organizations (HMOs) to provide medical coverage to people living with HIV (PLHIVs), as contained in Circular Letter No. 2019-30, issued by Insurance Commissioner Dennis B. Funa on June 21.

The document is in line with Republic Act (RA) No. 11166, or the Philippine HIV and AIDS Policy Act, signed by President Rodrigo Duterte in December 2018.

Under the circular, the IC will implement and develop policies that will ensure compliance with Section 42 of RA 11166, which states that no person/s living with HIV “shall be denied or deprived of private health insurance under an HMO on the basis of a person’s HIV status.”

Section 49 of the law also prohibits “denial of health services, or being charged with a higher fee, on the basis of actual, perceived or suspected HIV status.”

HMOs are expected to provide coverage to PLHIVs under the following conditions: he/she is undergoing proper medical treatment; he/she has a favorable risk profile; and the results of the medical examinations required by the HMO are within normal limits.

But the IC circular isn’t completely PLHIV-friendly.

Notably, HMO applicants may still be required to undergo HIV testing “based on parameters such as, but not limited to, age, total amount at risk, and occupation/lifestyle; provided that the applicant voluntarily consents to such testing pursuant to Article IV of RA 11166,” the IC said. This “HIV testing shall be performed by health facilities recognized by the Department of Health and have the capacity to provide services on HIV testing and counseling.”

Also notably, the insurance regulator allows HMOs to temporarily suspend or decline the application of PLHIVs who has other medical conditions or other risk factors which would have also resulted in the suspension or denial of the application even if not HIV positive. These include kidney, liver or cardiovascular diseases, hepatitis B or C, pulmonary tuberculosis, signs of infections brought on by a weakened immune system, smoking, and injection of illegal drugs.

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HMOs are also allowed to set limits of acceptance for PLHIVs depending on their age, payment terms or amount of coverage, upon approval of the IC. And – seemingly negating itself – HMOs may not decline an application solely based on the HIV status of the applicant, but they can still choose to deny coverage of PLHIVs.

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