Aug 12, 2023
Coverage of Preventive Services Without Cost Sharing
August 2023
Background
Non-grandfathered group health plans are required to cover those items considered to be preventive under provisions originally included in the Affordable Care Act (PHSA §2713) without imposing any cost sharing. The list of items that are considered preventive continues to be updated by designated departments/agencies over time based on newly available medical treatments and best practices.
Preventive Services
Non-grandfathered group health plans are required to provide the following preventive services without imposing any copayments, coinsurance, deductibles, or other cost-sharing requirements:
- 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;
- 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 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
- Evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA for women.
Plans that maintain a network of providers are not required to cover services received out-of-network. In addition, plans may use “reasonable medical management techniques” to help control costs, such as requiring preauthorization or providing coverage for generic instead of brand name drugs. However, such techniques may only be used when the applicable recommendation or guideline does not specify the frequency, method, treatment, or setting for a particular preventive service – in other words, any medical management techniques may not conflict with the recommendations or guidelines.
In addition, plans must provide coverage for the recommended preventive service, without cost sharing, regardless of sex assigned at birth, gender identity, or gender of the individual otherwise recorded by the plan.
Recommendations are Continuously Changing
As noted above, the lists of items that are considered preventive continues to be updated by designated departments/agencies over time based on newly available medical treatments and best practices.
Generally, if a new service or item is added to the list of recommended preventive services, plans are required to cover it beginning with the first plan year starting on or after the date the recommendation is made. And services that constitute a recommended preventive service on the first day of a plan year must generally be covered through the end of the plan year.
Summary
Employers and plan administrators should be sure to check the updated lists of recommended items and services at least annually to ensure that their plan is not imposing cost sharing on anything that has been newly added. In addition, group health plans are required to ensure that participants are appropriately notified of the preventive items and services covered without cost sharing by the plan by including a statement in the summary plan description (SPD) and summary of benefits of coverage (SBC). Depending on the level of detail included in the SPD or SBC, this may mean making necessary updates and required notifications when covered items/services change.
Links for Further Resources
CDC Recommended immunization schedules:
HRSA Childhood Periodicity schedule
While every effort has been taken in compiling this information to ensure that its contents are totally accurate, neither the publisher nor the author can accept liability for any inaccuracies or changed circumstances of any information herein or for the consequences of any reliance placed upon it. This publication is distributed on the understanding that the publisher is not engaged in rendering legal, accounting, or other professional advice or services. Readers should always seek professional advice before entering into any commitments.
