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How Quickly Must We Comply With Revisions to the Preventative Services Requirement?

12.11.2019

Question: Our company sponsors a calendar-year, non-grandfathered major medical plan. How quickly must that plan comply with changes to the recommendations or guidelines relating to the coverage of preventive health services?

Answer: Plan sponsors should ensure that non-grandfathered group health plans cover all preventive services listed in the various federal recommendations and guidelines for plan years beginning one year or later after the applicable recommendation or guideline is issued. State laws may impose additional requirements on insurers, but such requirements aren’t superseded by the Affordable Care Act.

The website of the U.S. Department of Health and Human Services provides a list of the preventive services that must be covered without cost-sharing — including services for adults, women and children. This list is generally updated as recommendations and guidelines are changed over time by the:

  • U.S. Preventive Services Task Force
  • Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention
  • Health Resources and Services Administration

So, you should also monitor the lists on the websites of these organizations.

Because compliance is generally required for plan years beginning one year or later after the recommendation or guideline is issued, there will be an interval of at least a year between the date on which a recommendation or guideline is issued and the date on which your plan must cover the services listed in that recommendation or guideline without cost-sharing. For example, if a recommendation is adopted on July 1, 2019, your calendar-year group health plan would be required to cover those services beginning January 1, 2021.

However, for recommendations that are discontinued, group health plans must keep providing coverage through the end of the plan year in which the recommendation was withdrawn — unless the recommendation is downgraded to a “D” level or found to be unsafe. For instance, if a service is removed from the list on July 1, 2019, your group health plan would be required to cover that service through December 31, 2019. But if the recommendation was downgraded to a “D” level or found to be unsafe, your plan wouldn’t be obligated to cover that item or service through the end of the year.

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