EBSA Addresses Coverage Of Preventive Services

The Department of Labor’s Employee Benefit Security Administration (EBSA) issued another set of frequently asked questions (FAQ) about implementation of the Patient Protection and Affordable Care Act (ACA). Among other issues, these FAQs address the coverage of preventive services. The ACA added Public Health Service Act (PHSA) Sec. 2713, which requires non-grandfathered group health plans and health insurance coverage offered in the individual or group market to provide certain preventive services without cost sharing

Out-of-network services. The FAQs clarify that if a plan or issuer does not have in its network a provider who can provide a particular preventive service, the plan or issuer must cover the item or service when performed by an out-of-network provider and not impose cost sharing with respect to the item or service.

Recommendations of the USPSTF. 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) must be covered pursuant to PHSA Sec. 2713. The USPSTF recommends the use of aspirin for certain men and women when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm. Aspirin is generally available over-the-counter (OTC). The FAQs clarify that aspirin and other OTC-recommended items and services must be covered without cost sharing only when prescribed by a health care provider.

Another USPSTF recommendation is a colonoscopy as a screening procedure. The FAQs indicate that a plan or issuer may not impose cost sharing with respect to a polyp removal during a colonoscopy performed as a screening procedure. On the other hand, a plan or issuer may impose cost sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.

The FAQs also clarify that the USPSTF recommendation for genetic counseling and evaluation for routine breast cancer susceptibility gene (BRCA) testing includes both genetic counseling and BRCA testing, if appropriate, for a woman as determined by her health care provider.

ACIP recommendations. PHSA Sec. 2713 and interim final regulations require coverage for immunizations for routine use in children, adolescents, and adults that have in effect a recommendation by the Advisory Committee on Immunization Practices (ACIP) for routine use. The vaccines must be covered without cost-sharing requirements when the service is delivered by an in-network provider. The ACIP makes routine immunization recommendations for children, adolescents, and adults that are population-based (e.g., age-based), risk-based (e.g., underlying medical conditions, work-related, or other special circumstances that increase risk of illness), or are catch-up recommendations.

The FAQs indicate that in some circumstances, the ACIP makes a recommendation that applies for certain individuals rather than an entire population. In these circumstances, health care providers should determine whether the vaccine should be administered, and if the vaccine is prescribed by a health care provider consistent with the ACIP recommendations, a plan or issuer is required to provide coverage for the vaccine without cost-sharing.

New ACIP recommendations will be required to be covered without cost-sharing starting with the plan year (in the individual market, policy year) that begins on or after the date that is one year after the date the recommendation is issued. An ACIP recommendation is considered to be issued on the date on which it is adopted by the Director of the Centers for Disease Control and Prevention (CDC), which is the earlier of: the date the recommendation is published in the Mortality and Morbidity Weekly Report, or the date the recommendation is reflected in the Immunization Schedules of the CDC. Therefore, plans or issuers with respect to a plan can determine annually what vaccines recommended by ACIP must be covered by checking http://www.healthcare.gov/law/features/rights/preventive-care/index.html prior to the beginning of each plan year.

Women’s preventive services. PHSA Sec. 2713 requires, with respect to women, coverage of evidence-informed preventive care and screening provided for in comprehensive guidelines supported by Health Resources and Services Administration (HRSA), to the extent not already included in certain recommendations of the USPSTF.

The FAQs clarify that a plan or issuer may not cover only oral contraceptives. HRSA Guidelines ensure women’s access to the full range of FDA-approved contraceptive methods. Contraceptive methods that are generally available OTC are only included if the method is both FDA-approved and prescribed for a woman by her health care provider. The HRSA Guidelines do not include contraception for men.

The HRSA Guidelines specifically incorporate comprehensive prenatal and postnatal lactation support, counseling, and equipment rental. Accordingly, the items and services described in the HRSA Guidelines are required to be covered in accordance with the requirements of the interim final regulations (that is, without cost sharing, subject to reasonable medical management, which may include purchase instead of rental of equipment). Coverage of comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment extends for the duration of breastfeeding.

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