Most plans will be required to cover new preventive items and services beginning later this year or in 2023 (depending on the plan year), including ones related to condoms, double-electric breast pumps, suicide risk screening for adolescents, and diabetes screenings for certain populations.
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.
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 ("e;USPSTF"e;) are considered to be "e;preventive."e; 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 considered to be issued. Additionally, the Health Resources and Services Administration ("e;HRSA"e;) has updated preventive care and screening guidelines for women and for infants, children, and adolescents.
New Preventive Items and Services
The USPSTF newly covered items and services are as follows:
||Effective for Plan Years Beginning On or After
|Gestational Diabetes: Screening asymptomatic pregnant persons at 24 weeks of gestation or after
||Screening for gestational diabetes in asymptomatic pregnant persons at 24 weeks of gestation or after.
||September 1, 2022
|Prediabetes and Type 2 Diabetes: Screening asymptomatic adults aged 35 to 70 years who have overweight or obesity
||Screening for prediabetes and type 2 diabetes in adults aged 35 to 70 years who have overweight or obesity.
Clinicians should offer or refer patients with prediabetes to effective preventive interventions.
|September 1, 2022
|Chlamydia and gonorrhea screening for sexually active women, including pregnant persons 24 years or younger and 25 years or older who are at increased risk for infection
||Screening for chlamydia in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection.
Screening for gonorrhea in all sexually active women 24 years or younger and in women 25 years or older who are at increased risk for infection.
|October 1, 2022
|Aspirin use to prevent preeclampsia and related morbidity and mortality: preventive medication pregnant persons at high risk for preeclampsia
||Use of low-dose aspirin (81 mg/day) as preventive medication after 12 weeks of gestation in persons who are at high risk for preeclampsia.
||October 1, 2022
|Prevention of dental caries (cavities) in children younger than 5 years: screening and interventions
||Prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride.
Apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption.
|January 1, 2023
Effective for plan years beginning on or after January 1, 2023, the HRSA newly covered items and services specifically for women are as follows:
|Obesity Prevention in Midlife Women
||Counseling midlife women aged 40 to 60 years with normal or overweight body mass index ("BMI") (18.5-29.9 kg/m2) to maintain weight or limit weight gain to prevent obesity. Counseling may include individualized discussion of healthy eating and physical activity.
|Breastfeeding Services and Supplies
||Breastfeeding equipment and supplies must currently be covered. New guidance expands on the description to specifically include double electric breast pumps (including pump parts and maintenance) and breast milk storage supplies. Access to double electric pumps should be a priority to optimize breastfeeding and should not be predicated on prior failure of a manual pump. Breastfeeding equipment may also include equipment and supplies as clinically indicated to support dyads with breastfeeding difficulties and those who need additional services.
||Male condoms must be covered.
|Screening for Human Immunodeficiency Virus Infection ("HIV")
||HIV screening for all adolescent and adult women must currently be covered. New guidance specifies that adolescent and adult women ages 15 and older can receive a screening test for HIV at least once during their lifetime. Earlier or additional screening should be based on risk and rescreening annually or more often may be appropriate beginning at age 13 for adolescent and adult women with an increased risk of HIV infection. Risk assessment and prevention education for HIV infection begins at age 13 and continues as determined by risk.
|Well-Woman Preventive Visits
||Women must currently be offered at least one preventive care visit per year beginning in adolescence and continuing across the lifespan. New guidance indicates that preventive services may be completed at a single or as part of a series of visits that take place over time to obtain all necessary services depending on a woman’s age, health status, reproductive health needs, pregnancy status, and risk factors. Well-women visits include pre-pregnancy, prenatal, postpartum and interpregnancy visits.
Effective for plan years beginning on or after January 1, 2023, the HRSA newly covered items and services specifically for children and adolescents are as follows:
- An assessment for risks for cardiac arrest or death in ages 11-21 years was added.
- An assessment for hepatitis B virus infection in newborn to 21-year olds was added.
- Screening for suicide risk for ages 12-21 to the current Depression Screening category was added.
- Psychosocial/behavioral assessment coverage was expanded to behavioral/social/emotional screening for newborn to 21-year olds.
- There is a clarifying reference to dental fluoride varnish and fluoride supplementation.
Employers sponsoring non-grandfathered group health plans should review the various preventive care requirements effective for their upcoming plan years. Such coverage must be provided in-network, without cost-sharing.
Fully insured health plans: Carriers are generally responsible for compliance and should include these benefits as applicable.
Self-funded health plans: Discuss with TPAs to ensure coverage is in effect for plan years that begin on or after the applicable effective dates.