2022 coverage of preventive services in non-grandfathered group health plans
Employers, take note: Several new or modified preventive care recommendations have been issued in the past year.
The Affordable Care Act’s (ACA) preventive services mandate for non-grandfathered plans requires certain preventive services be covered in-network without cost-sharing for plan participants. The ACA uses the following when determining the preventive services that must be covered:
- Evidence-based items or services rated A or B in the United States Preventive Services Task Force (USPSTF) recommendations.
- Recommendations of the Advisory Committee on Immunization Practices adopted by the Director of the Centers for Disease Control and Prevention (CDC).
- Comprehensive guidelines for infants, children, and adolescents supported by the Health Resources and Services Administration (HRSA).
- Comprehensive guidelines for women supported by the Health Resources and Services Administration (HRSA) that are not otherwise addressed by the recommendations of the USPSTF.
The final preventive services regulations, issued in July 2015, contain guidelines for when plans must incorporate any modified recommendations. A group health plan must cover a new or updated recommended preventive service starting in the plan year that begins on or after exactly one year from the issue date.
Related: Compliance calendar: Your guide to 2021 and beyond
New (or modified) preventive care recommendations for non-grandfathered health plans
The following are new or modified preventive care recommendations that were issued between the end of the year in 2020 to current date:
Updated Recommendation on Cardiovascular Disease Prevention in Adults (Issue Date: November 2020). The USPSTF issued a revised recommendation statement regarding adults with cardiovascular disease risk factors. The USPSTF recommends offering or referring adults with cardiovascular disease risk factors to behavioral counseling interventions to promote a healthy diet and physical activity. This recommendation replaces the 2014 USPSTF recommendation, and targets adults with known hypertension or elevated blood pressure, elevated lipid levels or dyslipidemia, and mixed or multiple risk factors (e.g., metabolic syndrome or estimated 10-year CVD risk of ≥7.5%).
In contrast to the previous recommendation statement, the current recommendation does not cover adults with impaired glucose tolerance or type 2 diabetes mellitus. This population is covered in a separate recommendation.
Updated Recommendation for Lung Cancer Screening for Adults (Issue Date: March 2021).
The USPSTF issued a revised recommendation statement regarding lung cancer screening for adults. The USPSTF recommends annual screening for lung cancer with low-dose computed tomography (LDCT) in adults aged 50 to 80 years who have a 20 pack-year smoking history and currently smoke or have quit within the past 15 years. Screening should be discontinued once a person has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability or willingness to have curative lung surgery.
This recommendation replaces the 2013 USPSTF recommendation on screening for lung cancer. In 2013 the USPSTF recommended annual screening for lung cancer with LDCT in adults aged 55 to 80 years who have a 30 pack-year smoking history and currently smoke or have quit within the past 15 years. For this updated recommendation, the USPSTF has changed the age range and pack-year eligibility criteria.
Updated Colorectal Cancer Screening Recommendation (Issue Date: May 2021).
The USPSTF issued a revised recommendation statement regarding screening for colorectal cancer. In the current recommendation, while continuing to recommend colorectal cancer screening in adults aged 50 to 75 years (A recommendation), the USPSTF now recommends offering screening starting at age 45 years (B recommendation). This recommendation replaces the 2016 USPSTF recommendation on screening for colorectal cancer.
New guidance on current HIV PrEP recommendation
In June 2019, the USPSTF issued a new recommendation (for plan years beginning on or after June 30, 2020) that expanded access to preexposure prophylaxis (PrEP) to help prevent the transmission of Human Immunodeficiency Virus (HIV) infection. The USPSTF recommends that clinicians offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are not infected with HIV and are at high risk of HIV infection.
On July 19, 2021, the Departments of Health and Human Services, Labor, and the Treasury issued new FAQs to clarify the coverage of PrEP. The new guidance confirms that cost-sharing protections extend to the ancillary and support services that are needed for an effective PrEP regimen. This means that all non-grandfathered plans must cover those services, alongside PrEP medication, without cost-sharing. These items or services include:
- Testing for HIV, Hepatitis B and C, creatinine, and pregnancy
- Sexually transmitted infection screening and counseling Adherence counseling Associated office visits
As with all preventive care guidelines, plans may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for the provision of a recommended preventive service to the extent not specified in the applicable recommendation or guideline.
Since not all plans may be currently in compliance with this requirement, the Departments are providing a 60-day enforcement grace period from the date the FAQs were issued (i.e., September 17, 2021). During this time, the Departments will not take enforcement action against a plan or insurer that fails to provide coverage of these services.
Employers and TPAs of non-grandfathered plans under the ACA should ensure that they are following the most updated guidance regarding preventive care benefits. In addition, changes to preventive care benefits may need to be updated in the plan document and summary plan description as well as any other employee communication materials that address these benefits.
Corrie Cripps is a plan drafter/compliance consultant with The Phia Group. She specializes in plan document drafting and review, as well as a myriad of compliance matters, notably including those related to the Affordable Care Act.
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