By: Jessica Waltman, Principal, Forward Health Consulting
Federal regulators recently released frequently asked questions (FAQ) guidance about how health insurance issuers and group health plans need to implement the Affordable Care Act’s (ACA) preventive care requirements. This round of FAQs specifically explains how non-grandfathered health insurance plans must provide preventive care benefits to people at high risk of contracting the human immunodeficiency virus (HIV). They clarify how plans and issuers need to apply ACA preventive care standards to the entire scope of each federal preventive care recommendation. Plus, the FAQs explain how plans and issuers may apply medical cost management practices to preventive care coverage. The FAQs focus on HIV pre-exposure prophylaxis services specifically but also address general ACA preventive care principles.
The ACA requires all plans without grandfathered status to cover specific preventive care services without applying participant cost-sharing requirements. The list of preventive care services that plans and issuers must cover on a first-dollar basis includes services that have an “A” or “B” rating in the current recommendations of the United States Preventive Services Task Force (USPSTF). On June 10, 2019, the USPSTF released an “A” rating recommendation that clinicians offer pre-exposure prophylaxis (PrEP) with “effective antiretroviral therapy to persons who are at high risk of human immunodeficiency virus (HIV) acquisition.” The recommendation describes PrEP as a comprehensive intervention comprised of both antiretroviral medication and essential support services. The support care includes a clinical assessment to ensure the therapy is appropriate for the individual. It also covers a variety of screening tests and medication adherence counseling. When offered as part of PrEP, all these services qualify as preventive care under the ACA.
Based on the timing of the recommendation, applicable plans and issuers had to start covering PrEP and its related services without applying cost-sharing in plan or policy years beginning on or after June 30, 2020. However, some plans and issuers only covered antiretroviral therapy on a first-dollar basis and not all related services. The new FAQs clarify that when a preventive care recommendation like PrEP includes multiple components of care, plans and issuers should cover all parts without cost-sharing. Since many carriers and plans did not fully understand the scope of the requirement before the publication of these FAQs, there will be no federal enforcement against plans that have not covered the full range of necessary services for the next 60 days.
The FAQs also address how plans and issuers can legally apply medical management to PrEP specifically and preventive care in general. Reasonable limits on the frequency, method, treatment, or setting of preventive care are permitted if the relevant federal guidelines do not address them. For example, with PrEP, the USPSTF recommendation addresses the frequency of some services, so a plan or issuer needs to follow their guidelines. However, the recommendation does not require the use of brand-name medications. So, a plan or issuer could limit first-dollar coverage to the generic version and require cost-sharing for anyone who chose the brand-name medication. In that case, a plan or issuer would need to make accommodations if the generic were medically inappropriate for a specific individual. These guidelines are valid for PrEP and they are also transferable to medical management for all ACA preventive care services.