Federal regulators recently called healthcare plan sponsors’ attention to new preventive care requirements, and indicated as well the regulators’ growing impatience with the failure by many plans to adequately comply with certain long-standing preventive care mandates, particularly the mandate related to contraceptive drugs and supplies.
One of the Affordable Care Act’s (ACA) claims to fame is its mandate that most non-grandfathered group healthcare plans provide cost-free coverage for in-network preventive services to plan enrollees. Among the preventive services that must be covered are evidence-based items or services with an “A” or “B” rating by the United States Preventive Services Task Force (USPSTF) and preventive care and screenings for women, children and infants provided in guidelines supported by the Health Resources and Services Administration (HRSA).
Starting with plan years beginning on or after May 31, 2022 (i.e., Jan. 1, 2023, for calendar year plans), group plans subject to the preventive care mandate must cover without cost sharing a colonoscopy (along with things like prior consultation, bowel preparation meds, anesthesia services, etc.) conducted after a positive “non-invasive stool-based” screening test or direct visualization screening test (e.g., sigmoidoscopy, CT colonography). In addition, a colonoscopy for individuals ages 45-49 is now embraced by the coverage mandate for plan years beginning on or after May 31, 2022.
Regulators indicate that participant complaints to federal agencies have proliferated over the years, complaints indicating some non-grandfathered plans subject to the requirement to provide any FDA-approved contraceptive drug or device are playing fast and loose with the rules. This trend compelled regulators to warn plans that ALL FDA-approved, cleared or granted contraceptive products that are determined by an individual’s medical provider to be medically appropriate for the individual must be covered without cost sharing, whether or not specifically identified in the current FDA Birth Control Guide. The following are examples of violations the federal regulators are seeing and investigating with plans, carriers and pharmacy benefit managers:
- Denying coverage for all or particular brand name contraceptives (even with a provider’s medically necessary determination)
- Requiring individuals to satisfy step-therapy or “fail first” protocols, that is, requiring the individual to try one or more other services or products within the same method (or even other methods) of contraception before approving the service or product that the individual’s provider deemed medically appropriate and had initially prescribed (“methods” include barrier methods, hormonal methods and implanted devices as well as education and training)
- Failing to provide an easily accessible, transparent and expedient exception process
Breast pumps and other HRSA recommendations
Several other preventive services will join the list of those that non-grandfathered plans must cover, beginning with plan years beginning in 2023:
- Double electric breast pumps
- Obesity counseling for women ages 40 to 60
- Universal suicide risk screening (added to the current depression screening category) for ages 12 to 21
- Cardiac arrest risk assessment in ages 11-21
- Hepatitis B risk assessment for newborn to age 21
Lockton comment: Lockton maintains a master grid of all ACA-required preventive care. Contact your Lockton account team for a copy.