What Preventive Services Must Our Group Health Plan Cover Without Cost-Sharing?

QUESTION: Our company sponsors a non-grandfathered major medical plan. How do we know what preventive services must be covered without cost-sharing?

ANSWER: The HHS website lists three sets of preventive services (for all adults, women, and children) that must be covered without cost-sharing under the Affordable Care Act (ACA) preventive health services rules. The lists generally correspond with the grade A and B recommendations of the U.S. Preventive Services Task Force (USPSTF), the vaccine recommendations of the CDC’s Advisory Committee on Immunization Practices (ACIP), and the guidelines for women’s and children’s preventive services provided by the Health Resources and Services Administration (HRSA). HHS generally updates its website listings as recommendations and guidelines change over time, but you should also regularly monitor the lists on each organization’s website.

Your company’s non-grandfathered health plan generally must cover all preventive services listed in each organization’s recommendations and guidelines for plan years beginning one year or more after the date the applicable recommendation or guideline is issued. Thus, there will generally be an interval of at least a year between the date on which a recommendation or guideline is issued and the date on which your plan must cover the services listed in that recommendation or guideline without cost-sharing. For example, if your plan operates on a calendar year, and a recommendation is adopted on July 1, 2022, your plan would be required to cover those services beginning January 1, 2024. If a recommendation is discontinued, your plan must continue to provide coverage through the end of the plan year in which the recommendation was discontinued, unless the recommendation is downgraded to a “D” level or is found to be unsafe.

Note that some services have been added with shortened timeframes for compliance. For example, plans must provide coverage within 15 business days of a USPSTF or ACIP recommendation regarding qualifying coronavirus preventive services, including COVID-19 vaccinations (see our Checkpoint article). Based on the ACIP recommendation for COVID-19 vaccinations, your plan had to cover FDA-approved COVID-19 vaccinations starting January 5, 2021, consistent with the scope of the FDA’s approval, including additional doses (see our Checkpoint article). In addition, state laws may impose additional requirements on insurers, and these requirements are not superseded by the ACA’s general preventive services requirements.

For more information, see EBIA’s Health Care Reform manual at Section XII.C (“Coverage of Preventive Health Services”), EBIA’s Group Health Plan Mandates manual at Sections XIV.C (“Required Preventive Health Services Coverage”) and XVI.C (“COVID-19: Mandated Coverage of Diagnostic and Preventive Services”), and EBIA’s Self-Insured Health Plans manual at Section XIII.C.1 (“Preventive Health Services”).

Contributing Editors: EBIA Staff.

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