The Insurance Commission (IC) has issued underwriting guidelines for health maintenance organisations (HMOs) in line with the assessment of risks for persons with actual, perceived, or suspected to be with HIV.
In a statement, the IC said, “The issue on HIV requires a comprehensive approach in 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. 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,” said Insurance Commissioner Dennis Funa.
Under the guidelines, an HMO cannot decline an application of a person living with HIV (PLHIV) on the sole basis of his or her HIV status.
An HMO may provide coverage to a PLHIV if the applicant is undergoing proper medical treatment; the applicant has a favourable risk profile; and the results of the medical examinations required by insurance companies are within normal limits.
In case of newly-discovered HIV positive individuals, HMOs may temporarily suspend the acceptance of newly-discovered HIV positive individuals for a period of one year from the start of continuous anti-retro viral treatment (ART).
“The one-year period is necessary for the purpose of evaluation of compliance with and efficacy of the ART,” the IC said.
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.
Co-morbidity in HIV has been defined as a disease outside the scope of an AIDs-defining illness. The most common co-morbidities among PLHIV include diabetes mellitus, cardiovascular disease, respiratory diseases, and hepatic diseases.
“As to the benefits and terms of an HMO contract, HMOs must seek the IC’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,” the IC added. A