Guidelines in the HMO Underwriting of Applicants with Actual, Perceived, or Suspected HIV Status

June 21, 2019

INSURANCE CIRCULAR LETTER NO. 2019-30

Supersedes: NONE

 

WHEREAS, Republic Act No. 11166, otherwise known as the "Philippine HIV and AIDS Policy Act," was signed by President Rodrigo R. Duterte into law on 20 December 2018, thereby repealing Republic Act No. 8504, otherwise known as the "Philippine AIDS Prevention and Control Act of 1998";

WHEREAS, Section 42 of Republic Act No. 11166 provides that no person/s living with HIV "x x x shall be denied or deprived of private health insurance under a Health Maintenance Organization (HMO) x x x on the basis of a person's HIV status"; and that this Commission "x x x shall implement this provision and shall develop the necessary policies to ensure compliance";

WHEREAS, Section 49 (g) of Republic Act No. 11166 prohibits the "denial of health services, or being charged with a higher fee, on the basis of actual, perceived, or suspected HIV status" and considers the same a discriminatory act;

WHEREAS, in the interest of effective implementation of the above-quoted provisions of Republic Act No. 11166, this Commission finds a need to issue various guidelines the underwriting of HMO product applicants with actual, perceived, or suspected HIV status;

NOW THEREFORE, in accordance with the undersigned's power to issue circulars concerning the regulation and supervision of the HMO industry pursuant to Section 4 of Executive Order No. 192, Series of 2015, and in accordance with Section 42 of Republic Act No. 11166, the following Guidelines in the HMO Underwriting of Applicants with Actual, Perceived, or Suspected Human Immunodeficiency Virus ("HIV") Status are hereby promulgated and adopted, to wit:

1. Voluntary HIV Testing. — An HMO may require applicants 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 Republic Act No. 11166. Said HIV testing shall be performed by health facilities recognized by the Department of Health (DOH) and has the capacity to provide services on HIV testing and counseling. DACcIH

2. Evaluation of Compliance with and Efficacy of Treatment. — An HMO may temporarily suspend the acceptance of newly-discovered HIV positive (+) individuals for a period not exceeding one (1) year from the start of continuous Anti-retroviral Therapy ("ART") in order to evaluate compliance with and the efficacy of treatment.

3. Grant of HMO Coverage. — An HMO may provide HMO coverage to an individual diagnosed to be infected with HIV or Person Living with HIV ("PLHIV"), if: (a) the PLHIV is undergoing proper medical treatment; and (b) said PLHIV has a favorable risk profile; and (c) the results of the medical examinations required by the HMO are within normal limits. Said requirements may include the following, to wit:

3.1. Routine requirements based on the applicant's age and total amount at risk;

3.2. HIV Medical Questionnaire, filled out by the attending physician;

3.3. Three (3) consecutive tests for CD4 cell count not older than six (6) months (submission of copies of results is required);

3.4. Current Viral Load count (Plasma HIV-1 RNA) not older than six (6) months (submission of copy of result is required);

3.5. Treatment or therapy course, or must be undergoing ART;

3.6. Hepatitis B profile;

3.7. Hepatitis C profile;

3.8. Regular blood chemistry profile, including liver and kidney function tests;

3.9. Non-smoker;

3.10. Chest x-ray results must be normal, without pulmonary tuberculosis ("PTB") or other pulmonary infections;

3.11. No early signs of other co-morbidities, such as renal disease and/or coronary artery disease ("CAD");

3.12. No signs of opportunistic infections.

 The HMO shall have the right to require original or certified true copies of the above-mentioned requirements. HSCATc

4. Additional Underwriting Requirements. — The HMO may request the PLHIV for additional documents or evidence that may be necessary for the proper underwriting of the PLHIV's HMO application.

5. Cost of Special Underwriting Requirements. — The HMO may require the PLHIV applicant to defray the reasonable cost/s of special underwriting requirements relative to his or her application.

6. Modification of Plan Benefits and Terms. — An HMO may, upon prior approval of this Commission, set limits of acceptance for PLHIVs as regards age, payment term/s, and/or amount of HMO coverage. Said limits, however, shall be reasonable and shall not be discriminatory, whether actual or perceived.

7. Underwriting Decisions. — The HMO cannot decline an application of a PLHIV on the sole basis of his or her HIV status. However, the HMO may temporarily suspend or decline the PLHIV's application when presented with co-morbidities, medical conditions, or other risk factors that would lead to the same underwriting decision based on the HMO's underwriting guidelines without taking into account said applicant's HIV status. Such risk profiles include, but are not limited to, the following:

7.1. With co-morbidity/ies (e.g., kidney, liver, or cardiovascular diseases);

7.2. With Hepatitis B or C;

7.3. With PTB;

7.4. With signs of opportunistic infection/s;

7.5. Smoker (present or history);

7.6. Intravenous injection of illegal drugs (present or history);

7.7. Other declinable medical condition/s (e.g., chronic kidney failure, uncontrolled diabetes and/or hypertension, cancer under Stage 4 or with presence of metastases);

7.8. Declinable occupational risk/s;

7.9. Declinable geographical/territorial risk/s;

7.10. Declinable avocation (dangerous hobbies) risk/s;

7.11. Declinable financial profile risk.

8. Separability Clause. — If any provision or part of this Circular Letter is declared unconstitutional, the remaining parts or provisions not affected shall remain in full force and effect. IDTSEH

9. Effectivity. — This Circular Letter shall take effect immediately.

For guidance and strict compliance.

(SGD.) DENNIS B. FUNAInsurance Commissioner