Preventive Care Regulatory Framework

Updates to clinical guidelines related to screening frequency, age, method or setting can lead to a change in plan coverage levels. What can be covered as a “free” preventive screening?


May 09, 2023

A fresh look at updated screening guidelines and evolving testing methods to assist employers in evaluating ways to improve their members’ screening compliance and reduce hidden cost barriers to accessing preventive care.

The USPSTF creates recommendations for clinical preventive services with respect to age, frequency and the conditions for which these measures have been proven to manage risk. The USPSTF aims to promote better health for Americans by offering recommendations based on scientific data regarding the best way to prevent illness and extend life. The Affordable Care Act (ACA), in turn, requires most group health plans and insurers to cover procedures and medicines rated ‘A’ or ‘B’ by the USPSTF without cost sharing. Such coverage levels may also extend to other services recommended based on other federal agency guidelines, including recommendations for women and children from HRSA and immunizations recommended by the CDC Advisory Committee on Immunization Practices (ACIP).3.4

For plan designs that come with tax-advantaged health savings accounts (HSAs), employers must also follow the Internal Revenue Service (IRS) rules. These rules dictate which procedures and treatments can bypass the deductible but still may carry a coinsurance cost. The IRS issued guidance for high-deductible health plans (HDHPs) with HSAs expands the definition of preventive care that plans can cover before the deductible is satisfied, going beyond the original ACA list of services.

Court Decisions Affecting Coverage of Preventive Services

Following an initial ruling last year, a Federal district court judge issued an order for the remedy in the case of Braidwood Management v. Becerra on March 30, 2023. The order immediately blocked the ACA's requirement for no cost coverage of preventive services recommended or required by the USPSTF. The order also ruled that the requirement to cover PrEP medications for HIV prevention violated the rights of the plaintiffs who have religious objections to PrEP. The Federal government has appealed the decision and requested a stay of the injunction invalidating the USPSTF preventive services requirements.

Preventive Care Visits and the Role of PCPs

Primary care accounts for less than 10% of total health care expenditures

Primary care providers (PCPs) are often seen by their patients as their most trusted health advisors. In the U.S., two-thirds of the population has an established PCP; the remaining third lacks access to these physicians mainly due to a national shortage of practitioners in rural areas.5

Establishing a relationship with a PCP is an essential part of prevention, as this relationship helps patients adopt healthier habits and improves patient education and adherence to preventive screening guidelines.6 Furthermore, most preventive services are delivered within the primary care setting. The most basic form of preventive care is an annual preventive exam performed by the patient’s PCP to assess their overall health and screen for health risks. Basic screenings, including those for cholesterol, blood pressure and blood sugar, allow a PCP to identify any issues that may become medical concerns in the future. Mental health screenings are also increasingly incorporated into routine primary care visits.

Since the pandemic, health care has been engaged in a transition from brick-and-mortar care to widespread adoption of telehealth. This transition has led to many changes for providers and patients alike. Telehealth-enabled primary care allows some patients easier access to care, more flexible follow-up and faster specialty referrals.7 One study from Elevance Health found that 32% of individuals in the U.S. had used virtual primary care (VPC). Of that third, 94% were satisfied with the experience and 79% indicated that VPC has helped them take charge of their health.8

The growing acceptance of accessing primary care through telemedicine may provide an additional venue for improving access to timely care and preventive services utilization. Several providers are beginning to offer virtual primary care services to develop ongoing relationships with their patients. In late 2021, multiple carriers, including UnitedHealth Group, Humana and Aetna, as well as other regional plans, announced virtual-first primary care initiatives focused on longitudinally connecting patients to PCPs via telehealth.9 Building these longitudinal relationships can create a better connection between patients and their PCPs. In addition, positioning primary care to maximize its convenience may be a crucial step to improving overall compliance with preventive care guidelines.

The Difference between Preventive and Diagnostic Services

As patients access preventive services, one challenge is differentiating between diagnostic and preventive services. Out-of-pocket costs vary widely based on why a test or service is ordered While preventive services can be covered without cost sharing, any follow-up tests or screenings administered due to the presence of symptoms, higher risk-level or inability to determine health status based on initial screenings are deemed diagnostic and therefore may lead to out-of-pocket costs. The most common examples of such a surprise cost are sonograms performed after mammography. Because these services may serve different purposes (diagnostic versus preventive) in certain scenarios, communication and education are important to prevent employees from receiving bills for services they may have thought would be 100% covered by their plan. It is important for patients to understand why a test or service is ordered: The same test can be preventive, diagnostic or routine chronic care depending on the reason it was ordered.

Source: Medical Mutual. The Difference Between Preventive and Diagnostic Medical Care. Accessed March 9, 2023.

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