The Department of Labor (the “DOL”), in conjunction with the Department of Health and Human Services and the Treasury (together, the “Departments”), has issued FAQs (Part XVIII) regarding implementation of the Affordable Care Act, including among other things guidance on preventive services. Here is what the FAQs say on this topic:
Coverage of Preventive Services. Public Health Service (“PHS”) Act section 2713 and the interim final regulations relating to coverage of preventive services require non-grandfathered group health plans to provide benefits for, and prohibit the imposition of cost-sharing requirements with respect to, the following:
• Evidenced-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 (“USPSTF”) with respect to the individual involved, except for the recommendations of the USPSTF regarding breast cancer screening, mammography, and prevention issued on or around November 2009, which are not considered current;
• Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices (“ACIP”) of the Centers for Disease Control and Prevention (“CDC”) with respect to the individual involved;
• With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (“HRSA”); and • With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA, to the extent not already included in the current recommendations of the USPSTF.
If a recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of that service, the plan can use reasonable medical management techniques to determine any coverage limitations.
These requirements do not apply to grandfathered health plans.
New USPSTF recommendations. On September 24, 2013, the USPSTF issued new recommendations with respect to breast cancer. Specifically, the USPSTF revised its “B” recommendation regarding medications for risk reduction of primary breast cancer in women. The September 2013 recommendation now says:
The USPSTF recommends that clinicians engage in shared, informed decision making with women who are at increased risk for breast cancer about medications to reduce their risk. For women who are at increased risk for breast cancer and at low risk for adverse medication effects, clinicians should offer to prescribe risk-reducing medications, such as tamoxifen or raloxifene.
Accordingly, for plan years beginning one year after the date the recommendation or guideline is issued (in this case, plan years beginning on or after September 24, 2014), non-grandfathered group health plans will be required to cover such medications for applicable women without cost sharing subject to reasonable medical management.