The Affordable Care Act (ACA) regulations set forth mandatory medical plan design changes starting in 2014 that extended to all non-grandfathered group health plans.
For example, non-grandfathered group health plans are required to cover those items considered to be preventive under the Affordable Care Act (PHSA §2713) without imposing in-network cost sharing. The list of items that are considered preventive continues to be updated by designated departments/agencies over time based on newly available medical treatments and best practices.
Plans that maintain a network of providers are not required to cover services received out-of-network so long as there is adequate in-network access to each required preventive care service. In addition, plans may use reasonable medical management techniques to help control costs, such as requiring preauthorization or providing coverage for generic instead of brand name drugs. However, such techniques may only be used when the applicable recommendation or guideline does not specify the frequency, method, treatment, or setting for a particular preventive service – in other words, any medical management techniques may not conflict with the recommendations or guidelines.
In addition, plans must provide coverage for the recommended preventive service, without cost sharing, regardless of sex assigned at birth, gender identity, or gender of the individual otherwise recorded by the plan.
Recommendations are Continuously Changing
As noted above, the lists of items that are considered preventive continues to be updated by designated departments/agencies over time based on newly available medical treatments and best practices.
Generally, if a new service or item is added or an existing service is updated, plans are required to cover it beginning with the first plan year starting on or after the one year anniversary following the date the recommendation is made/updated. For example, if the change is made/updated on 3/1/22, the group health plan must include the change on their next plan anniversary on/after 3/1/23. This means a group plan renewing on 1/1 would not have to make the change until 1/1/24 using the dates above.
The exception to this is COVID-19 vaccinations/boosters: they must be covered immediately, and must be covered both in- and out-of-network without cost sharing during the public health emergency.
Women’s Preventive Care Updates December 30, 2021 to be Effective Plan Years Beginning On/After December 30, 2022
The Health Resources & Services Administration (HRSA) women’s preventive services were updated December 30, 2021. “This 2021 update adds one additional service, Preventing Obesity in Midlife Women, and revises five services: Breastfeeding Services and Supplies, Contraception, Screening for Human Immunodeficiency Virus Infection, Counseling for Sexually Transmitted Infections, and Well-Woman Preventive Visits.”
Non-grandfathered plans renewing on/after December 30, 2022, will need to include the following updates considered as preventive care:
- Counseling to prevent obesity in women aged 40 to 60 years with normal or overweight body mass index;
- Double electric breast pumps, pump parts and maintenance, and breast milk storage supplies;
- The full range of women’s contraceptives listed in the recently updated FDA Birth Control Guide;
- Screening for HIV infection for all adolescent and adult women aged 15 and older at least once during their lifetime, and risk assessment and prevention education beginning at age 13; and
- Pre-pregnancy, prenatal, postpartum, and interpregnancy well-woman visits.
Employers with self-funded non-grandfathered plans should ensure their plan administrator is updating the plan at each renewal to avoid inadvertently imposing unauthorized cost sharing or medical management restrictions on new or updated preventive care requirements. In addition, group health plans must notify participants of the preventive items and services covered without cost sharing by the plan by including a statement in the summary plan description (SPD) and summary of benefits of coverage (SBC). Depending on the level of detail included in the SPD or SBC, this may mean making necessary updates and required notifications when covered items/services change.
Links for Further Resources
- gov: https://www.healthcare.gov/coverage/preventive-care-benefits/
- ACIP Vaccine guidelines and recommendations: https://www.cdc.gov/vaccines/hcp/acip-recs/index.html
- CDC Recommended immunization schedules:
- HRSA Childhood periodicity schedule: https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf
- HRSA women’s guidelines: https://www.hrsa.gov/womens-guidelines/index.html
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