August 17, 2020
Preventive screenings refer to procedures like colonoscopies, mammograms and other tests that detect health problems before symptoms develop. More broadly, preventive care includes screenings as well as vaccinations, annual check-ups and wellness visits. 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?
The United States Preventive Services Task Force (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 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 the Health Resources and Services Administration (HRSA) and the Centers for Disease Control and Prevention (CDC).
For plan designs that come with tax-advantaged health savings accounts, employers must also follow the Internal Revenue Service (IRS) rules. These rules dictate which procedures and treatments can by-pass the deductible, but still may carry a coinsurance. Recently updated IRS guidance for high-deductible health plans (HDHPs) with health savings accounts (HSAs) expands the definition of preventive care that plans can cover before the deductible is satisfied, going beyond the original ACA list of services. The expanded list includes chronic condition treatments like beta-blockers, insulin and other glucose- lowering agents, as well as statins, among others. While screening tests for HIV, cancer, obesity and others included on the ACA list of services must still be covered without out-of-pocket costs to members regardless of their health plan design, this IRS guidance gives employers offering HDHPs with HSAs more latitude for bypassing the member deductible for claims related to medications and other services deemed preventive for certain chronic conditions.
Employers may look to design their plans so that deductible is not applied to preventive drug therapies and services to encourage adherence to preventive care and medications. Many employers rely on their pharmacy benefit manager (PBM) partners to develop preventive drug lists of medications that bypass the deductible in HDHPs. Some employers choose to customize these lists to include medications they deem preventive based on their interpretation of the rules.
- 1 | United States Preventive Services Task Force (USPSTF). Recommendation Topics. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics. Accessed July 8, 2020.
- 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.
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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.
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- 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.
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- 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.
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IntroductionEmployers' Guide to Preventive Care
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Part 1Preventive Care: Regulatory Framework
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Part 2Preventive Care: "Annual" Visits and Preventive Screening Considerations
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Part 3Preventive Care: Role of Preventive Screenings in Managing Chronic Conditions
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Part 4Preventive Care: Cancer Screening Guidelines
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Part 5Preventive Care: Emerging Preventive Care Coverage Considerations
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Part 6Preventive Care: Opportunities for Employers
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