Benefits Strategy

Preventive Care: Emerging Preventive Care Coverage Considerations

Federal guidelines will continue to evolve as new evidence emerges on the utility and promise of various screenings and other procedures of detecting serious illnesses early enough to delay disease progression.

August 17, 2020

Preventive Care Guide

By taking a fresh look at some of the updated screening guidelines and evolving test methods, this guide will assist employers in evaluating ways to improve their members' compliance with preventive screening and remove cost barriers to accessing preventive care.

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Preventive Care Considerations for Reproductive Health

In December 2019, the Health Resources and Services Administration (HRSA) updated its Women’s Preventive Services Guidelines to include the following required services, effective for plan years beginning on or after December 17, 2020 (January 1, 2021 for calendar year plans):

Condition	Preventive Guidelines/Recommendations	Coverage Considations
Anxiety	Screening for anxiety should be completed for adolescent and adult women including those who are pregnant or postpartum. As ideal screening intervals are unknown, clinical judgement should be used to determine screening frequency.	Plans typically set limits for services if USPSTF or other federal agency recommendations do not include frequency, method, or setting as ”reasonable medical management.” When clinical recommendations for preventive services change, they must be implemented for the plan year that follows one year after the recommendations were finalized. For services no longer recommended, plans may stop coverage after 60 days following a written notice to participants.
Perinatal Depression	Preventive interventions may include referrals to counseling for pregnant and postpartum persons at increased risk of perinatal depression.
Preeclampsia Screening	Preeclampsia screenings should be conducted through blood pressure measurements made throughout pregnancy.

Genetic Testing as Preventive Care

Genetic screening tests aimed at identifying the risk of developing cancers or chronic diseases are rapidly entering the market. Have we reached a point where these tests can be considered “preventive” and therefore able to detect health problems before symptoms are present? Currently, these tests only identify the gene mutations associated with increased risk/ probability of developing certain conditions. Such probability in many cases can be relatively low. As with other screenings, the cost and potential for unnecessary follow-up services should be considered in the context of potential benefits of early screening and detection.

There are several genomic conditions that, if identified via a genetic test, can alter the frequency of targeted screening and overall course of treatment. One example is those who have the BRCA1 or BRCA2 gene who choose to begin having mammograms done earlier in life and more frequently to increase the likelihood of early detection. The population prevalence of these genomic conditions in the United States vary. The USPSTF recommends that women who have family members with breast, ovarian, tubal or peritoneal cancer receive genetic counseling and evaluation for BRCA1 and BRCA2 testing at zero out-of-pocket cost, but does not specify when these screenings should take place. Beyond this population, routine genetic testing is not recommended and has not received an ‘A’ or ‘B’ rating.

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2 | Business Group on Health. ACA Preventive Services Chart. https://www.businessgrouphealth.org/resources/aca-preventive-services-chart. Accessed July 31, 2020.
3 | Business Group on Health. HSA/HDHPs Can Now Provide Pre-Deductible Coverage for Insulin and Other Chronic Condition Treatments. https://www.businessgrouphealth.org/resources/hsa-hdhps-can-now-provide-pre-deductible-coverage-for-insulin-and-other-chronic-condition-treatments. Accessed July 8, 2020.
4 | Primary Care Collaborative. Spending for Primary Care Fact Sheet. https://www.pcpcc.org/sites/default/files/resources/PCPCC%20Fact%20Sheet%20PC%20Spend%20Aug%202018.pdf. Accessed July 31, 2020.
5 | Beckman AL, Becerra AZ, Marcus A, et al. Medicare Annual Wellness Visit association with healthcare quality and costs. Am J Manag Care. 2019;25(3):e76-e82. Published 2019 Mar 1.
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7 | American Academy of Family Physicians (AAFP). Choosing Wisely® annual EKGs for low-risk patients. https://www.aafp.org/patient-care/clinical-recommendations/all/cw-ekg.html. Accessed July 8, 2020.
8 | Benjamin EJ, Virani SS, Callaway CW, et al. Heart disease and stroke statistics—2018 update: a report from the American Heart Association. Circulation. 2018;137:e67–e492.
9 | Pippitt K, Li M et al. Diabetes mellitus: Screening and diagnosis. Am Fam Physician. 2016 Jan 15;93(2):103-109.
10 | United States Preventive Services Task Force. Final Recommendation Statement: Abnormal Blood Glucose and Type 2 Diabetes Mellitus: Screening. October 26, 2015. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/screening-for-abnormal-blood-glucose-and-type-2-diabetes. Accessed July 8, 2020.
11 | United States Preventive Services Task Force. Screening for Cardiovascular Disease Risk with Electrocardiography: Recommendation Statement. https://www.aafp.org/afp/2018/0915/od1.html. Am Fam Physician. 2018 Sep 15;98(6):online.
12 | United States Preventive Services Task Force (USPSTF). Final Recommendation Statement: Statin Use for the Primary Prevention of Cardiovascular Disease in Adults: Preventive Medicine. November 13, 2016. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/statin-use-in-adults-preventive-medication. Accessed July 31, 2020.
13 | United Kingdom National Health Service (NHS). Diagnosis: Chronic kidney disease. August 29, 2019. https://www.nhs.uk/conditions/kidney-disease/diagnosis/. Accessed July 8, 2020.
14 | United States Preventive Services Task Force (USPSTF). Understanding Task Force Recommendations: Screening for Chronic Kidney Disease. August 2012. https://www.uspreventiveservicestaskforce.org/Home/GetFileByID/1881. Accessed July 31, 2020.
15 | Business Group on Health. New ACA Preventive Service Coverage Requirement for HIV (PrEP). https://www.businessgrouphealth.org/resources/new-aca-preventive-service-coverage-requirement-for-hiv-prep. Accessed July 8, 2020.
16 | Business Group on Health. HIV/AIDS: Despite Progress, Much Work Remains. https://www.businessgrouphealth.org/en/resources/hiv-aids-despite-progess-much-work-remains. Accessed July 31, 2020.
17 | Centers for Disease Control and Prevention. Breast Cancer Screening Guidelines for Women. https://www.cdc.gov/cancer/breast/pdf/BreastCancerScreeningGuidelines.pdf. Accessed July 8, 2020.
18 | National Institute of Health: National Cancer Institute. Dense Breasts: Answers to commonly asked questions. https://www.cancer.gov/types/breast/breast-changes/dense-breasts. Accessed July 8, 2020.
19 | Mayo Clinic. Virtual Colonoscopy. https://www.mayoclinic.org/tests-procedures/virtual-colonoscopy/about/pac-20385156. Accessed July 8, 2020.
20 | Centers for Disease Control and Prevention. Colorectal (Colon Cancer): Screening Tests. https://www.cdc.gov/cancer/colorectal/basic_info/screening/tests.htm. Accessed July 8, 2020.
21 | Simon S. Colorectal Cancer Screening: What Are My Options? American Cancer Society. March 2, 2020. https://www.cancer.org/latest-news/understanding-tests-that-screen-for-colon-cancer.html. Accessed July 8, 2020.
22 | Cavallo J. Solving the mystery of why colorectal cancer Is on the rise in young adults: A conversation with Kimmie Ng, MD, MPH. The ASCO Post. https://www.ascopost.com/issues/june-25-2019/solving-the-mystery-of-why-colorectal-cancer-is-on-the-rise-in-young-adults/. Accessed July 8, 2020.
23 | Centers for Disease Control and Prevention. Lung Cancer: Who Should Be Screened for Lung Cancer? https://www.cdc.gov/cancer/lung/basic_info/screening.htm. Accessed July 8, 2020.
24 | American Cancer Society. Can lung cancer be found early? https://www.cancer.org/content/cancer/en/cancer/lung-cancer/detection-diagnosis-staging/detection.html. Accessed July 8, 2020.
25 | Business Group on Health. Webinar Presentation: A conversation about the Impact of the expanding field of genetic testing on employers and key considerations for coverage. February 4, 2020.
26 | United States Preventive Services Task Force (USPSTF). Final Recommendation Statement: BRCA-Related Cancer: Risk Assessment, Genetic Counseling, and Genetic Testing. August 20, 2019. https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/brca-related-cancer-risk-assessment-genetic-counseling-and-genetic-testing. Accessed July 8, 2020.