Preventive Care: Emerging Preventive Care Coverage Considerations

Federal guidelines will continue to evolve as new evidence emerges on the utility and promise of various screenings and other procedures of detecting serious illnesses early enough to delay disease progression.

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By taking a fresh look at some of the updated screening guidelines and evolving test methods, this guide will assist employers in evaluating ways to improve their members' compliance with preventive screening and remove cost barriers to accessing preventive care.

Federal guidelines will continue to evolve as new evidence emerges on the utility and promise of various screenings and other procedures of detecting serious illnesses early enough to delay disease progression.

Preventive Care Considerations for Reproductive Health

In December 2019, the Health Resources and Services Administration (HRSA) updated its Women’s Preventive Services Guidelines to include the following required services, effective for plan years beginning on or after December 17, 2020 (January 1, 2021 for calendar year plans):


Condition

Preventive Guidelines/Recommendations

Coverage Considations

Anxiety

Screening for anxiety should be completed for adolescent and adult women including those who are pregnant or postpartum. As ideal screening intervals are unknown, clinical judgement should be used to determine screening frequency.

Plans typically set limits for services if USPSTF or other federal agency recommendations do not include frequency, method, or setting as ”reasonable medical management.” When clinical recommendations for preventive services change, they must be implemented for the plan year that follows one year after the recommendations were finalized. For services no longer recommended, plans may stop coverage after 60 days following a written notice to participants.

Perinatal Depression

Preventive interventions may include referrals to counseling for pregnant and postpartum persons at increased risk of perinatal depression.

Preeclampsia Screening

Preeclampsia screenings should be conducted through blood pressure measurements made throughout pregnancy.

Genetic Testing as Preventive Care

Genetic screening tests aimed at identifying the risk of developing cancers or chronic diseases are rapidly entering the market. Have we reached a point where these tests can be considered “preventive” and therefore able to detect health problems before symptoms are present? Currently, these tests only identify the gene mutations associated with increased risk/ probability of developing certain conditions. Such probability in many cases can be relatively low. As with other screenings, the cost and potential for unnecessary follow-up services should be considered in the context of potential benefits of early screening and detection.

There are several genomic conditions that, if identified via a genetic test, can alter the frequency of targeted screening and overall course of treatment. One example is those who have the BRCA1 or BRCA2 gene who choose to begin having mammograms done earlier in life and more frequently to increase the likelihood of early detection. The population prevalence of these genomic conditions in the United States vary. The USPSTF recommends that women who have family members with breast, ovarian, tubal or peritoneal cancer receive genetic counseling and evaluation for BRCA1 and BRCA2 testing at zero out-of-pocket cost, but does not specify when these screenings should take place. Beyond this population, routine genetic testing is not recommended and has not received an ‘A’ or ‘B’ rating.

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TABLE OF CONTENTS

  1. Preventive Care Considerations for Reproductive Health
  2. Genetic Testing as Preventive Care