January 22, 2019

On and On It Goes: Preventive Care Coverage Updates Under the Affordable Care Act

The Affordable Care Act (ACA) introduced mandatory coverage for a wide array of preventive care services. Section 2713 of the ACA requires most health plans to provide coverage for various preventive care services without cost-sharing requirements (e.g., copayments, deductibles, or coinsurance).

Each year, a new set of refinements and requirements are introduced to plan coverage to reflect changes made to the recommendations on which the ACA relies. Calendar-year health plans must implement changes made to these recommendations in 2017 by the start of 2019. Similarly, calendar-year health plans must cover recommendation revisions made in 2018 by the start of 2020.

For 2019, calendar-year health plans must address the following changes:

  • U.S. Preventive Services Task Force A and B recommendations are as follows:

    • New requirement: preeclampsia screening, including monitoring of blood pressure throughout pregnancy for signs of preeclampsia

    • Modified requirements: folic acid supplementation, obesity screening for children and adolescents, and vision screening for children 

  • Immunization schedule changes modified the standards for, and therefore coverage of, the following vaccines for children and adolescents age 18 or younger:

    • Hepatitis B vaccine

    • Poliomyelitis vaccine

    • Diphtheria, tetanus toxoids, and acellular pertussis vaccine

    • Haemophilus influenzae type B vaccine

    • Human papillomavirus vaccine

    • Influenza vaccine

    • Meningococcal vaccine

    • Pneumococcal vaccine 

  • Bright Futures recommendation modifications for child preventive care include the following:

    • Updates to the timing and follow-up requirements for a number of existing recommendations

    • Bilirubin screening requirements for newborns

    • Screening for maternal depression

For 2020, calendar-year health plans must address the following changes:

  • U.S. Preventive Services Task Force A and B recommendations are as follows:

    • New requirement: osteoporosis screening for postmenopausal women younger than 65 years at increased risk of osteoporosis (created from prior osteoporosis screening mandates, this requirement clarifies the population for screening, introduces reference to menopause, and references clinical risk assessment for determining increased risk)

    • New requirement: intimate partner violence screening for women of reproductive age, including providing or referring those who screen positive to ongoing support services

    • Modified requirements: cervical cancer screening, fall prevention for older adults, obesity screening and counseling for adults, osteoporosis screening for women 65 years and older, skin cancer behavioral counseling, syphilis screening for pregnant women, and screening for unhealthy alcohol use in adults 

  • Immunization schedule changes modified the treatment standards for the following vaccines for children and adolescents age 18 or younger:

    • Hepatitis B vaccine

    • Measles, mumps, and rubella (MMR) vaccine

    • Influenza vaccine

    • Meningococcal vaccine

    • Polio vaccine

    • Rotavirus vaccine

    • Pneumococcal vaccine 

  • Immunization schedule changes revised standards for the following vaccines for adults:

    • Tdap or Td vaccines

    • MMR vaccine

    • Zoster vaccines

    • HPV vaccine

    • Men ACWY vaccine 

  • The Uniform Panel of the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children added screening for certain kinds of spinal muscular atrophy.

Not every change adds coverage. In April 2018, the U.S. Preventive Services Task Force discontinued its recommendation to provide vitamin D supplementation in order to prevent falls for community-dwelling adults age 65 years and older who are at increased risk for falls. Since this measure is now actively discouraged, health plans are no longer required to provide coverage for such supplements. Where preventive care recommendations have been deleted but not discouraged, coverage must be continued until the end of the plan year in which the change to recommendations is made.

The details of most of these modifications go well beyond what is included in most health plans. For this reason, the main concern is one of health plan administration. To the extent plan terms spell out the ACA’s preventive care mandates, however, changes may be necessary to add new requirements and to modify existing ones.

© 2019, Ogletree, Deakins, Nash, Smoak & Stewart, P.C., All Rights Reserved.

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About this Author

Stephen Riga, Ogletree Deakins Law Firm, Labor Law and Privacy Attorney
Of Counsel

Mr. Riga concentrates his practice in the area of employee benefits and privacy and security issues.

Mr. Riga's benefits practice includes work with funds and employers to design, maintain, merge and terminate qualified retirement plans and health and welfare plans. Mr. Riga prepares determination letters and voluntary compliance program submissions and assists employers and funds on COBRA, Medicare Part D, and HIPAA compliance. Mr. Riga evaluates contribution and withdrawal liability obligations, and identifies retirement and health and welfare...

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