Preventive Care: Regulatory Framework

Updates to clinical guidelines related to screening frequency, age, method or setting can lead to a change in plan coverage levels. What can be covered as a “free” preventive screening?

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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.

Preventive screenings refer to procedures like colonoscopies, mammograms and other tests that detect health problems before symptoms develop. More broadly, preventive care includes screenings as well as vaccinations, annual check-ups and wellness visits. Updates to clinical guidelines related to screening frequency, age, method or setting can lead to a change in plan coverage levels. What can be covered as a “free” preventive screening?

The United States Preventive Services Task Force (USPSTF) creates recommendations for clinical preventive services with respect to age, frequency and the conditions for which these measures have been proven to manage risk. The Affordable Care Act (ACA), in turn, requires most group health plans and insurers to cover procedures and medicines rated ‘A’ or ‘B’ by the USPSTF without cost sharing. Such coverage levels may also extend to other services recommended based on other federal agency guidelines, including the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC).

For plan designs that come with tax-advantaged health savings accounts, employers must also follow the Internal Revenue Service (IRS) rules. These rules dictate which procedures and treatments can by-pass the deductible, but still may carry a coinsurance. Recently updated IRS guidance for high-deductible health plans (HDHPs) with health savings accounts (HSAs) expands the definition of preventive care that plans can cover before the deductible is satisfied, going beyond the original ACA list of services. The expanded list includes chronic condition treatments like beta-blockers, insulin and other glucose- lowering agents, as well as statins, among others. While screening tests for HIV, cancer, obesity and others included on the ACA list of services must still be covered without out-of-pocket costs to members regardless of their health plan design, this IRS guidance gives employers offering HDHPs with HSAs more latitude for bypassing the member deductible for claims related to medications and other services deemed preventive for certain chronic conditions.

Employers may look to design their plans so that deductible is not applied to preventive drug therapies and services to encourage adherence to preventive care and medications. Many employers rely on their pharmacy benefit manager (PBM) partners to develop preventive drug lists of medications that bypass the deductible in HDHPs. Some employers choose to customize these lists to include medications they deem preventive based on their interpretation of the rules.

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