By: HUB’s EB Compliance Team

Recent guidance has expanded the list of preventive services group health plans are required to cover under the Affordable Care Act and clarified some existing items.

Updates to Women’s Preventive Services Guidelines

On December 30, 2021, the Health Resources and Services Administration (“HRSA”) of the Department of Health and Human Services (“HHS”) adopted updated preventive services guidelines. Non-grandfathered group health plans and health insurers are required to cover these preventive health services starting with the first plan year beginning on or after December 30 of this year. For calendar year plans, this means the 2023 plan year.

The one new required covered service is counseling to prevent obesity in midlife women. Midlife women are defined as women aged 40 to 60 years. The counseling is available for those midlife women with normal or overweight body mass index (BMI) to help them maintain weight or limit weight gain to prevent obesity.

The updated covered services are:

  • Breastfeeding Services and Supplies. Comprehensive lactation support services (including consultation, counseling, education by clinicians and peer support services, and breastfeeding equipment and supplies) during the antenatal, perinatal, and postpartum periods. These services are intended to ensure the successful initiation and maintenance of breastfeeding. The equipment and supplies include double electric breast pumps (including pump parts and maintenance) and breast milk storage supplies. Breastfeeding equipment may also include equipment and supplies as clinically indicated to support dyads with breastfeeding difficulties and those who need additional services.
  • Contraception. Adolescent and adult women will have access to the full range of contraceptives and contraceptive care that are FDA-approved, -granted, or -cleared. This includes screening, education, counseling, and provision of contraceptives (including in the immediate postpartum period). Contraceptive care also includes follow-up care (e.g., management, evaluation, and changes, including the removal, continuation, and discontinuation of contraceptives).
  • Screening for HIV Infection. Adolescent and adult women, ages 15 and older, will be able to receive a screening test for human immunodeficiency virus (HIV) at least once during their lifetime. Earlier or additional screening will be based on risk. Rescreening annually or more often may be appropriate beginning at age 13 for those at increased risk.  Risk assessment and prevention education for HIV infection must be paid for beginning at age 13 and continuing as determined by risk. A screening test for HIV is recommended for all pregnant women upon initiation of prenatal care with potential rescreening based on risk. Rapid HIV testing is recommended for pregnant women who present in labor with an undocumented HIV status.
  • Counseling for Sexually Transmitted Infections. Plans and carriers will need to cover behavioral counseling by a health care clinician or other appropriately trained individual for sexually active adolescent and adult women at an increased risk for sexually transmitted infections (STIs). For those without identified risk factors, counseling to reduce the risk of STIs will be covered based on the provider’s determination on an individual basis.
  • Well-Woman Preventive Visits. Plans will be required to cover at least one preventive care visit per year beginning in adolescence. Well-women visits also include pre-pregnancy, prenatal, postpartum, and interpregnancy visits.

As a reminder, the HRSA guidance is intended and written for health care providers.  Therefore, sometimes the contours of how plans should cover these items or services is unclear. It is possible that the relevant agencies may issue guidance that fleshes out how these recommendations are to be applied to plans.

New(ish) FAQs

Additionally, last month, the FAQs initially requiring plans to cover over-the-counter at-home COVID-19 tests grabbed headlines. However, buried near the bottom of the FAQs was some additional preventive services guidance.

Specifically, beginning with plan years on or after May 31, 2022, plans must cover a colonoscopy (and associated items and services) that follows either a non-invasive stool-based screening test (like a Cologuard) or a direct visualization test (e.g., sigmoidoscopy or CT colonography). In other words, if one of these less invasive tests results in the doctor recommending a follow-up colonoscopy, the plan will have to cover it. The FAQs provide additional detail on this requirement.

The FAQs also note that the federal government has received complaints about plans not providing adequate coverage of contraceptives, as required by the preventive services mandate under the Affordable Care Act. The FAQs note that the relevant departments are actively investigating these complaints.

Takeaways

All employers sponsoring non-grandfathered group health plans should be aware of these changes. Employers with self-funded plans, in particular, should consider confirming with their TPAs that they will have systems in place to handle these claims by their respective effective dates, and notify plan participants of these changes through the issuance of a Summary of Material Modifications or the release of a new Summary Plan Description (SPD) (if the plan is subject to ERISA).

If you have any questions, please contact your HUB Advisor. View more compliance articles in our Compliance Directory.

NOTICE OF DISCLAIMER

Neither Hub International Limited nor any of its affiliated companies is a law or accounting firm, and therefore they cannot provide legal or tax advice. The information herein is provided for general information only, and is not intended to constitute legal or tax advice as to an organization’s specific circumstances. It is based on Hub International's understanding of the law as it exists on the date of this publication. Subsequent developments may result in this information becoming outdated or incorrect and Hub International does not have an obligation to update this information. You should consult an attorney, accountant, or other legal or tax professional regarding the application of the general information provided here to your organization’s specific situation in light of your organization’s particular needs.