When the Departments of Labor (DOL), Health and Human Services (HHS), and Treasury – all three agencies – outlined requirements for group health plans and insurers to cover and reimburse registrants for at-home COVID-19 test kits without cost sharing, starting Jan. 15, they also clarified required coverage for colonoscopies, contraceptives and other types of preventive care at no cost to plan enrollees, citing complaints about denied requests for those services .
Advice, in the form of a new set of frequently asked questions and answersreleased by the DOL’s Employee Benefits Security Administration on January 10, addresses coverage of follow-up colonoscopies for individuals ages 45 to 49 and clarifies how plans and insurers should cover all contraceptives under the law on Affordable Care (ACA).
Under the ACA, nongrandfathered private health plans, including employer-sponsored group health plans, must cover certain preventive services without cost sharing, particularly services rated “A” or “B » by the ACA. Recommendations from the US Preventive Services Task Forceaccording to Katie Keith, director of health policy and legal initiative at the O’Neill Institute for National and Global Health Law at Georgetown University, writing for the Health Affairs Forefront blog.
Colonoscopy coverage
In 2016, the task force recommended colorectal cancer screening in people aged 50 to 75; However, “some consumers have had a screening colonoscopy when they expected it to be free, but received large bills once their procedure was coded as diagnostic,” Keith noted. The three agencies subsequently clarified that the coverage without cost sharing applied to prior consultations with a specialist, medication preparation, anesthesia, polyp removal and biopsies.
Then, in May 2021, the task force extended its recommendation for colorectal cancer screening to people ages 45 to 49.
The Jan. 10 guidance “confirms that insurers and plans are required to cover a follow-up colonoscopy, without cost sharing,” if there are indications of colon-related bleeding, for all individuals age 45 and older , wrote Keith. Health insurance plans must offer this coverage without cost sharing for plan years beginning on or after May 31, 2022.
Contraceptive coverage
The three agencies also addressed the scope of contraceptive coverage without cost sharing under the ACA.
An ongoing concern, Keith noted, is that “insurers and plans limit access to a range of FDA (Food and Drug Administration) approved contraceptives, or impose cost sharing,” for example by discouraging the use of IUDs requiring a prerequisite. authorization – or make it more difficult or more expensive to stay on a brand name contraceptive even if the generic version causes side effects.
The guidance “clearly states that insurers and plans must cover, without cost sharing, all FDA-approved, cleared, or licensed contraceptive products that are deemed medically appropriate by an individual’s provider.” This is true regardless of whether the contraceptive product is specifically identified or not. in the FDA Birth Control Guide or not.”
Expanded use of preventive services
Also on January 11, the HHS Office of the Assistant Secretary for Planning and Evaluation released ACA preventive services without cost sharingwith evidence from studies examining the ACA’s effect on increasing colon cancer screenings, vaccinations, contraceptive use, and chronic disease screenings.
“We estimate that more than 150 million people with private health coverage now benefit from coverage of ACA preventive services without cost sharing, across a range of services and terms,” the report said. “Studies demonstrate increased access to preventive services, including colon cancer screening, HPV vaccination, annual Medicare wellness visits, and contraceptive use. coverage… can also help people access the Medicare program at age 65 in better health.
Ongoing research “can help monitor the impact of the ACA on access to care, use of preventive services, health disparities, and long-term health outcomes,” the report states.
Preventative services for women and children
Finally, in another release on January 11, HHS announced that its Health Resources and Services Administration (HRSA) updated comprehensive guidelines for preventative care and screening for women and childrenspecifying that preventive care that must be covered without cost sharing includes breastfeeding services and supplies, preventive care visits for well women, access to contraceptives and contraceptive counseling, screening for human immunodeficiency virus (HIV) and advice on sexually transmitted infections.
For the first time, for example, the guidelines will require group health plans to offer coverage with no co-pays or deductibles for double electric breast pumps for new parents and suicide risk screening for adolescents, for plan years starting in 2023.
HRSA posted online a table comparing its current and updated guidelines for different types of preventive services.
“These updated guidelines help ensure we are providing essential services to keep families healthy, based on the latest science and data available,” said HHS Secretary Xavier Becerra.
Related SHRM article:
No cost sharing for PrEP-related HIV prevention services, SHRM onlineAugust 2021
