Employee Benefits-DOL Issues Guidance On Coverage of Preventive Services Under The Affordable Care Act

The U.S. Department of Labor (the “DOL”), in conjunction with the U.S. Department of Health and Human Services (the “HHS”) and the Treasury (collectively, the “Departments”), have jointly issued Frequently Asked Questions (“FAQs”) Part 35, regarding implementation of the Affordable Care Act and other matters.  One topic covered in these FAQs is coverage of preventive services under the Affordable Care Act.  Here is what the FAQs say on this topic:

Background.  PHS Act section 2713 and its implementing regulations require non-grandfathered group health plans to cover, without the imposition of any cost-sharing requirements, the following recommended preventive services:

  • evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (the “USPSTF”) with respect to the individual involved, except for the recommendations of the USPSTF regarding breast cancer screening, mammography, and prevention issued in or around November 2009, which are not considered in effect for this purpose;
  • immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices (the “ACIP”) of the Centers for Disease Control and Prevention (the “CDC”) with respect to the individual involved;
  • with respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (the “HRSA”); and
  • with respect to women, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by HRSA, to the extent not included in certain recommendations of the USPSTF.

If a recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of a recommended preventive service, then the plan may use reasonable medical management techniques to determine any such coverage limitations.

New Question.  HRSA updated its Women’s Preventive Services Guidelines on December 20, 2016. When must non-grandfathered group health plans begin offering coverage for preventive services without cost sharing based on the updated guidelines?

Answer.  Women’s preventive services are required to be covered without cost sharing in accordance with the updated guidelines for plan years beginning on or after December 20, 2017.  Until the new guidelines become applicable, non-grandfathered group health plans are required to provide coverage without cost sharing consistent with the previous HRSA guidelines and PHS Act section 2713 for any items or services that continue to be recommended.  HRSA’s updated women’s preventive services guidelines were recently released based on recommendations developed by the Women’s Preventive Services Initiative (the “WPSI”), a coalition of national health professional organizations and consumer and patient groups with expertise in women’s health.  The update is available at https://www.hrsa.gov/womensguidelines2016.

WPSI is led, through a competitive cooperative agreement, by the American College of Obstetricians and Gynecologists.  In developing these guidelines, WPSI engaged its coalition of health professional organizations and consumer and patient advocates to develop, review, and update recommendations for women’s preventive services.  These updated guidelines complement and build upon recommendations from entities such as the USPSTF.  These recommendations update prior work by the Institutes of Medicine (the “IOM”) to develop the initial Women’s Preventive Service Guidelines, meet a recommended five-year benchmark for updates (by the IOM), and help ensure the guidelines remain current with the existing science and evidence-based practices.  Similar to the processes of the USPSTF, ACIP, and Bright Futures for developing evidence-based guidelines, WPSI established a process for stakeholders to provide public comment that included defining the scope of the recommended guidelines, identifying and assessing the evidence base, and disseminating the final HRSA-supported guidelines.