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Agencies Clarify Coverage of Preventive Care Without Cost-Sharing

Plans told to provide no-cost coverage for colonoscopies, contraceptives

A doctor is talking to a patient in a doctor's office.

When the departments of Labor (DOL), Health and Human Services (HHS), and Treasury—the tri-agencies—outlined requirements for group health plans and insurers to cover and reimburse enrollees for at-home COVID-19 test kits without cost-sharing, beginning Jan. 15, they also clarified required coverage for colonoscopies, contraceptives and other types of preventive care at no cost to plan enrollees, citing complaints about denied claims for these services.

The guidance, in the form of a new set of frequently asked questions and answers, posted by the DOL's Employee Benefits Security Administration on Jan. 10, addressed coverage of follow-up colonoscopies for those ages 45 to 49 and clarified how plans and insurers should cover the full scope of contraceptives under the Affordable Care Act (ACA).

Under the ACA, nongrandfathered private health plans—including employer-sponsored group health plans—must cover certain preventive services without cost-sharing, specifically services given a rating of "A" or "B" by the U.S. Preventive Services Task Force recommendations, according to Katie Keith, director of the Health Policy and the Law Initiative at the O'Neill Institute for National and Global Health Law at Georgetown University, writing for the Health Affairs Forefront blog.

Coverage of Colonoscopies

In 2016, the task force recommended screening for colorectal cancer for those ages 50 to 75; however, "some consumers went in for a screening colonoscopy that they expected to be free only to receive significant bills after their procedure was coded as diagnostic," Keith noted. The tri-agencies subsequently clarified that coverage without cost-sharing applied to prescreening consultations with a specialist, preparation medications, anesthesia, and polyp removal and biopsies.

Then, in May 2021, the task force extended its recommendation for colorectal cancer screening to those ages 45 to 49.

The Jan. 10 guidance "confirms that insurers and plans are required to cover a follow-up colonoscopy, without cost-sharing," if there are indications of colon-related bleeding, for all people ages 45 and older, Keith wrote. Health plans must provide this coverage without cost-sharing for plan years beginning on or after May 31, 2022.

Contraceptive Coverage

The tri-agencies also addressed the scope of coverage for contraceptives without cost-sharing under the ACA.

An ongoing concern, Keith noted, is that "insurers and plans are limiting access to, or imposing cost-sharing for, a range of FDA [Food and Drug Administration]-approved contraceptives," such as discouraging the use of IUDs by requiring prior authorization—or making it harder or more expensive to stay on a brand-name contraceptive even if the generic version is causing side effects.

The guidance "makes clear that insurers and plans must cover, without cost-sharing, all FDA-approved, cleared, or granted contraceptive products that are deemed medically appropriate by an individual's provider. This is true regardless of whether the contraceptive product is specifically identified in the FDA Birth Control Guide or not."

Expanded Use of Preventive Services

Also on Jan. 11, the HHS Office of the Assistant Secretary for Planning and Evaluation issued ACA Preventive Services Without Cost-Sharing, with evidence from studies examining the effect of the ACA on increased colon cancer screenings, vaccinations, contraception use and chronic disease screenings.

"We estimate that more than 150 million people with private health coverage are now benefitting from the ACA's coverage of preventive services without cost-sharing, across a range of services and conditions," the report states. "Studies demonstrate increases in access to preventive services, including colon cancer screening, HPV vaccination, Medicare annual wellness visits, and contraceptive use. Investments in prevention in the early and middle decades of life, when people are more likely to be covered by private health coverage …  may also help people enter the Medicare program at age 65 in better health."

Ongoing research "can help monitor the impact of the ACA on access to care, use of preventive services, health disparities, and long-term health outcomes," the report stated.

Preventive Services for Women and Children

Finally, in another Jan. 11 posting, HHS announced that its Health Resources and Services Administration (HRSA) updated comprehensive preventive care and screening guidelines for women and children, clarifying that preventive care to be covered without cost-sharing includes breastfeeding services and supplies, well-woman preventive care visits, access to contraceptives and contraceptive counseling, screening for human immunodeficiency virus (HIV), and counseling for sexually transmitted infections.

For the first time, for example, the guidelines will require group health plans to provide coverage without a co-pay or deductible for double electric breast pumps for new parents and suicide risk screening for adolescents, for plan years starting in 2023.

HRSA posted online a chart comparing its current and updated guidelines for different types of preventive services.

"These updated guidelines help ensure that we're providing critical services to keep families healthy, based on the latest science and data available," HHS Secretary Xavier Becerra said.

Related SHRM Article:

No Cost-Sharing for PrEP-Related HIV Prevention Services, SHRM Online, August 2021


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