Insights

Updated Coverage to Mandated Preventive Services


In the last 12 months, there have been several changes to the preventive services that must be offered with no cost sharing. As background, the ACA requires non-grandfathered health plans to provide coverage for a range of preventive care services without cost-sharing requirements (such as copayments, deductibles or coinsurance requirements) for patients. The mandatory preventive care benefits required under the ACA include evidence-based screenings and counseling, routine immunizations, preventive services for children and youth, and preventive services for women.

The ACA's list of "Mandated Preventive Health Care Services" is subject to annual updates, and insurers and self-funded health plan administrators must ensure that their coverage requirements encompass each of the newly added items (as applicable) as of the first day of the plan year or policy year one year after the recommended update is issued. Additionally, plan documents, benefit schedules, summary plan descriptions (SPDs) and similar communications, and any related materials should be carefully reviewed and updated (where appropriate). Those updated documents should also be provided to plan participants.

The list for significant updates to the Mandated Preventive Health Care Services provided by the U.S. Preventive Services Task Force (USPSTF) are listed as follows (by order of effective date):

  • Hearing Loss. Screening for hearing loss in newborn infants (no longer required)
  • Depression (Adults). Screening for depression in the general adult population, including pregnant and postpartum women (mandated for plan years beginning on and after Jan. 31, 2017)
  • Depression (Children and Adolescents). Screening for major depressive disorder (MDD) in adolescents aged 12 to 18 years (mandated for plan years beginning on and after Feb. 28, 2017)
  • Aspirin. A low-dose aspirin for prevention of cardiovascular disease and colorectal cancer in adults aged 50-59 years who meet all of the following criteria:
    • Have a 10-year cardiovascular risk of 10% or greater
    • Aren't at increased risk for bleeding
    • Have a life expectancy of at least 10 years
    • Are willing to take low-dose aspirin daily for at least 10 years (mandated for plan years beginning on and after April 30, 2017)
  • Colorectal Cancer. Screening for colorectal cancer starting at age 50 and continuing until age 75 (mandated for plan years beginning on and after June 30, 2017)
  • Syphilis (Non-Pregnant Adults and Adolescents). Screening for syphilis infection in persons who are at increased risk for infection (mandated for plan years beginning on and after June 30, 2017)
  • Latent Tuberculosis Infection. Screening for latent tuberculosis infection (LTBI) in populations at increased risk (mandated for plan years beginning on and after Sept. 30, 2017)
  • Breastfeeding. Providing interventions during pregnancy and after birth to support breastfeeding (mandated for plan years beginning on and after Oct. 31, 2017)
  • Statin. Adults aged 40-75 years with no history of cardiovascular disease (CVD) use a low- to moderate-dose statin for the prevention of CVD events and mortality when they have one or more cardiovascular disease risk factors, and a calculated 10-year CVD event risk of 10% or greater; screening for cardiac risk may include assessment of blood pressure, smoking status, screening for lipid disorders and use of ACC/AHA CVD to estimate 10-yr risk (mandated for plan years beginning on and after Nov. 30, 2017)
  • Folic Acid. All women who are planning or capable of pregnancy take a daily supplement containing 0.4-0.8 mg (400-800 µg) of folic acid (mandated for plan years beginning on and after Jan. 31, 2018)
  • Preeclampsia. Screening for preeclampsia in pregnant women with blood pressure measurements throughout pregnancy (mandated for plan years beginning on and after April 30, 2018)
  • Obesity (Children and Adolescents). Screening for obesity in children and adolescents six years and older and offer to refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status (mandated for plan years beginning on and after June 30, 2018)
  • Vision (Children Aged 6 Months to 5 Years). Vision screening at least once in all children ages three to five years to detect amblyopia or its risk factors (mandated for plan years beginning on and after Sept. 30, 2018)

The Health Resources and Services Administration (HRSA) provided updates to the preventive services for women (incorporated into the Mandated Preventive Health Care Services), mandated for plan years beginning on and after Dec. 20, 2017:

  • Breast cancer screening for average-risk women. Mammography exams are to be performed at least biennially beginning at age 40 through age 74 (but age is not a basis to discontinue screening)
    • Women at increased risk for breast cancer should undergo mammography "periodically"
    • Imaging tests, biopsies or other interventions are required to be considered an integral part of "Screening"
  • Cervical cancer screening for average-risk women. Screening for cervical cancer:
    • For ages 21-29, PAP smear every 3 years
    • For ages 30-65, with cytology and human papillomavirus testing (HPV) testing with Pap smear every 5 years or a regular cytology alone (without HPV testing) every 3 years
    • Women with an average risk shouldn't be screened more than once every 3 years
  • Contraception. Adolescent and adult women must have access to the full range of female-controlled contraceptives to prevent unintended pregnancies and improve birth outcomes; counseling and follow-up care are included in this requirement
  • Screening for gestational diabetes mellitus. Pregnant women should be screened after 24 weeks of gestation, and women with risk factors for diabetes should be screened prior to 24 weeks of gestation
  • Screening for human immunodeficiency virus (HIV) infection. Coverage for preventive education and risk assessment in adolescents and all women, based on risk, is mandated; education and assessment occur annually based on risk, but may be more frequent for increased-risk cases
  • Screening for interpersonal and domestic violence. Annual screening for adolescents and women is required as is, when needed, the provision of or referral to initial intervention services, which include counseling, education, harm reduction strategies and referral to appropriate supportive services
  • Counseling for sexually transmitted diseases. Annual, directed behavioral counseling by a health care provider or other trained provider for sexually active adolescent and adult women at increased risk
  • Well-woman preventive visits. Preventive care visits to ensure that recommended preventive services (including preconception) are made on an annual basis, although several visits may be required, depending on health status and needs

The following are updates to the 2018 Immunization Practices provided by the Advisory Committee on Immunization Practices (ACIP) (incorporated into the Mandated Preventive Health Care Services). They are effective February 2018:

  • Revised the immunization schedule for children and adolescents age 18 or younger, including:
    • Hepatitis B vaccine
    • Poliomyelitis vaccine
    • Human papillomavirus (HPV) vaccine
    • Influenza vaccine
    • Meningococcal vaccine
    • Haemophilus vaccine
    • Meningococcal B vaccine
  • Updates to immunizations schedule for vaccines provided based on medical condition"
    • HIV
    • Pneumococcal
  • Revised requirements for:
    • Diphtheria and tetanus toxoids
    • Acellular pertussis
    • Hemophilia
    • Influenza type B and pneumococcal vaccines

The revised nominated conditions to the Recommended Uniform Screening Panel (RUSP) mandated for plan years beginning on and after February 2017 include:

  • Adrenoleukodystrophy (ALD)
  • MPS I (alpha-L-iduronidase deficiency)

There are significant changes made to the Bright Futures/American Academy of Pediatrics – Bright Futures Project Recommendations, which are mandated for plan years beginning on and after May 1, 2018), and include:

  • Updates to the timing and follow-up for a number of existing recommendations
  • New bilirubin screening requirements for newborns
  • New screening requirements for maternal depression
  • Other changes as set forth in official detailed schedules

Though the NFP Benefits Compliance team has provided these updates ad hoc in the past, going forward, we intend to summarize all changes to the Mandated Preventive Health Care Services list in October of each year so that plan sponsors have time to incorporate the new changes (if any) into the plan documents prior to the beginning of the then upcoming plan year.

Note: Plan sponsors (of non-grandfathered plans) should work with their medical and pharmacy benefit administrators to ensure that the new recommendations are implemented and determine if there's a cost impact to the plan. Further, the impact of some of these expansions is unknown, but it may be best to reach out to your stop-loss carrier to see if there are additional concerns.

USPSTF, Preventive Care Mandates »
HRSA, Women's Preventive Service Guidelines »
ACIP, 2018 Immunization Schedule for Children and Adolescents Aged 18 or Younger »
Recommended Uniform Screening Panel (RUSP) »
Bright Futures provided by the American Academy of Pediatrics »