A health maintenance organization cannot decline an application of a person with or HIV on the sole basis of his or her status, the Insurance Commission said Tuesday.
This was contained in the HMO underwriting guidelines issued by the commission on the assessment of risks of persons with actual, perceived, or suspected to be with HIV.
“The Insurance Commission issued the guidelines in the interest of the effective implementation of Republic Act No. 11166 or the Philippine HIV and AIDS Policy Act signed by President Duterte last December 2018,” Insurance Commissioner Dennis Funa said in a statement.
Under R.A. 11166, no person living with HIV shall be denied or deprived of private health insurance under an HMO on the basis of a person’s HIV status.
“The issue on HIV requires a comprehensive approach in the prevention, treatment, and impact alleviation. Despite free anti-retro viral treatment, the lack of HMO coverage for persons with HIV continues to be a source of economic strain to them and their families,” Funa said.
“Thus, there is a need to provide clear guidelines in the underwriting of applicants with actual, perceived, or suspected HIV status to ensure that they are not deprived of HMO coverage,” Funa said.
Under the guidelines, an HMO cannot decline an application of a person living with HIV on the sole basis of his or her HIV status.
An HMO may provide coverage to a person with HIV if the applicant is: 1) undergoing proper medical treatment; 2) the applicant has a favorable risk profile; and 3) the results of the medical examinations required by insurance companies are within normal limits.
In case of newly-discovered HIV positive individuals, HMO companies may temporarily suspend the acceptance of newly-discovered HIV positive individuals for a period of not more than one year from the start of continuous Anti-Retro Viral Treatment. The one-year period is necessary for the purpose of evaluation of compliance with and efficacy of the ART.
HMOs may temporarily suspend or decline an application of a PLHIV only if it presented with co-morbidities, medical condition, or other risk factors that would lead to the suspension or denial of the application without taking into account the applicant’s HIV status.
Comorbidity in HIV has been defined as a disease outside the scope of an AIDs-defining illness. The most common comorbidities among PLHIV include diabetes mellitus, cardiovascular disease, respiratory diseases, and hepatic diseases.
HMOs may require applicants to voluntarily undergo HIV testing provided that the applicant voluntarily consents to such testing pursuant to Article IV of R.A. No. 11166. The determination on whether
or not HIV testing is necessary depends on certain parameters such as the age, occupation or lifestyle of the applicant.
The guidelines likewise provide that the testing shall be performed by health facilities which have the capacity to provide services on HIV testing and counseling and are recognized by the Department of Health.
As to the benefits and terms of an HMO contract, HMOs must seek the Commission’s approval before it may set limits of acceptance for PLHIVs as regards age, payment terms, and/or amount of HMO coverage, provided that such limits are reasonable and not discriminatory.
According to the Department of Health, the Philippines has been reported to be one of the fastest-growing worldwide in terms of rate of increase in infections of HIV/AIDS with a reported 56,275 cumulative cases since 1984.
