Most plans will be required to cover new preventive items and services in 2021 and 2022, including several related to the human immunodeficiency virus ("HIV").
Additionally, the Coronavirus Aid, Relief, and Economic Security Act ("CARES Act") requires coverage for any COVID-19 related preventive care services within 15 days.
Non-grandfathered group health plans must provide coverage for in-network preventive items and services and may not impose any cost-sharing requirements (such as a copayment, coinsurance, or deductible) with respect to those items or services. If a plan or carrier does not have in its network a provider who can provide the required preventive care item or service, the plan or carrier must cover the item or service when performed by an out-of-network provider, and may not impose cost-sharing with respect to the item or service.
Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force ("USPSTF") are considered to be "preventive." The USPSTF recommendations can change and those changes generally apply for plan years that begin on or after the date that is one year after the date the new recommendation or guideline is issued.
New Preventive Items and Services
The newly covered items and services are as follows:
Effective for plan years beginning 2021 Abdominal aortic aneurysym screening: men: 1-time screening for abdominal aortic aneurysm with ultrasonography in men aged 65 to 75 years who have ever smoked.
Bacteriuria screening: pregnant women: Screening for asymptomatic bacteriuria using urine culture in pregnant persons.
Breast cancer preventive medication: Clinicians offer to prescribe risk-reducing medications, such as tamoxifen, raloxifene, or aromatase inhibitors, to women who are at increased risk for breast cancer and at low risk for adverse medication effects.
BRCA risk assessment and genetic counseling/testing: Primary care clinicians assess women with a personal or family history of breast, ovarian, tubal, or peritoneal cancer or who have an ancestry associated with breast cancer susceptibility 1 and 2 gene mutations with an appropriate brief familial risk assessment tool. Women with a positive result on the risk assessment tool should receive genetic counseling and, if indicated after counseling, genetic testing.
Hepatitis B screening: pregnant women: Screening for hepatitis B virus (HBV) infection in pregnant women at their first prenatal visit.
HIV preexposure prophylaxis (PrEP) for the prevention of HIV infection: Clinicians offer PrEP with effective antiretroviral therapy to persons who are at high risk of HIV acquisition.
HIV screening: adolescents and adults ages 15 to 65 years: Clinicians screen for HIV infection in adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk of infection should also be screened.
HIV screening: pregnant women: Clinicians screen for HIV infection in all pregnant persons, including those who present in labor or at delivery whose HIV status is unknown.
Perinatal depression: counseling and intervention: Clinicians provide or refer pregnant and postpartum persons who are at increased risk of perinatal depression to counseling interventions.
Gonorrhea prophylactic medication: newborns: Prophylactic ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum.
Effective for plan years beginning 2022
Hepatitis C virus infection screening: adults aged 18 to 79 years: Screening for hepatitis C virus (HCV) infection in adults aged 18 to 79 years.
Rapid Coverage for COVID-19 Vaccine
Although plans usually have one year to cover services recommended by the USPSTF, the CARES Act provides that new preventive services related to COVID-19 (e.g., a vaccine) must be covered by a non-grandfathered group health plan within 15 days. At this time, no such vaccine is available; however, a vaccine may become available later this year or in 2021.
It appears that this requirement applies only to non-grandfathered plans, but further guidance may extend such coverage to grandfathered plans.
Employers sponsoring non-grandfathered group health plans should review the various preventive care requirements effective for their 2021 plan years. Such coverage must be provided in-network, without cost-sharing.
For fully insured health plans carriers are generally responsible for compliance and should include these benefits as applicable. For self-funded health plans, employer should discuss with TPAs to ensure coverage is in effect for plan years that begin on or after January 1, 2021.
Should a vaccine for COVID-19 become available, group health plans will want to move quickly to ensure coverage is provided in-network without cost-sharing.
For a complete list of preventive items and services, visit: http://www.uspreventiveservicestaskforce.org/Page/Name/recommendations