Fate of Free Preventive Health Services Puts Employers on Edge

Many Americans who have obtained preventive services such as PrEP or anxiety screenings for children at no cost since the passage of the Affordable Care Act would have to pay out-of-pocket costs unless a recent court ruling is overturned.

One-third of the 46 preventive services that health insurance plans have been required to cover for free under Obamacare would be affected, an analysis of the district court decision by the University of Michigan’s Center for Value-Based Insurance Design found.

The court’s ruling, which potentially affects millions of Americans who receive coverage through employer and other private health plans, has employee benefits and human resources professionals calling for clarity on which services would now require workers to pay copays and deductibles.

A recent guidance from a quartet of federal agencies was seen as helpful, but more information is needed, they said.

The March 30 decision by Judge Reed O’Connor of the US District Court for the Northern District of Texas blocked an Obamacare requirement for health plans to pay in full for preventive health-care services that were recommended by the US Preventive Services Task Force after the ACA went into effect in 2010.

“Going back to the future and relying on obsolete evidence has important clinical, equity and policy implications,” Mark Fendrick, the center’s director, said in an email.

“The return of out-of-pocket costs for preventive care will likely disproportionately prevent the disadvantaged—and those most likely to benefit—from receiving these potentially life saving services,” said Fendrick, who helped draft the preventive care provisions of the Affordable Care Act.

Screenings for Lung Cancer, Diabetes

O’Connor’s ruling blocked an ACA requirement for health plans to pay in full for preventive health-care services that have an “A” or “B” rating from the task force.

An “A” or “B” letter grade indicates the task force finds there is high certainty that the services have a substantial or moderate net health benefit, according to the Kaiser Family Foundation.

The analysis by Fendrick’s center determined that one-third of services recommended by the task force would no longer be eligible for no-cost coverage.

They include services like the HIV-prevention drug regimen PrEP and screenings for lung cancer or gestational diabetes that were backed by the task force after 2010.

Another third of the services—those covered since before passage of the ACA in 2010—would continue to have no cost-sharing requirement under the court decision, Fendrick said. They include screenings for depression in adults and for breast cancer.

The analysis by Fendrick’s center found that the impact on another third of services was uncertain. Those involve services approved before March 2010 but whose recommendations were later substantially revised, such as screenings for osteoporosis, colorectal cancer, and cervical cancer.

“What is uncertain is whether payers will continue to cover the updated services even though they don’t have to,” Fendrick said. He said a survey by his center suggests that a majority might do that.

More Clarification Sought

The four federal agencies implementing the ACA issued guidance April 13 stipulating that health insurance plans continue to cover preventive services that were recommended before the law was enacted on March 23, 2010, without requiring cost-sharing.

Mark Wilson, vice president of health and employment policy and chief economist for the HR Policy Association, said in an interview that he has asked the Department of Labor to clarify which services carried the “A” and “B” Preventive Services Task Force ratings prior to enactment of the ACA.

“The Departments anticipate issuing guidance to further address the obligations to cover preventive services in light of the decision,” a DOL spokesman said in an email to Bloomberg Law.

Katy Johnson, senior counsel for health policy of the American Benefits Council, said in an interview that the agency guidance was helpful in clarifying that high-deductible health plans that are qualified for health savings accounts can continue to cover the “A” and “B” rating preventive services on a pre-deductible basis.

Employer groups had requested clarification of that point, Johnson said.

Meanwhile, the HHS’ move to appeal and to request a stay in the case means there may be limited immediate impact for employers and insurers, Wilson said.

“It locks in place everyone to continue to provide first-dollar coverage for the ‘A’ and ‘B’ recommendations of the task force until the litigation is resolved,” he said.

Lawmakers Weigh In

Lawmakers on Capitol Hill also are seeking answers.

House and Senate Democratic health committee leaders last week sent letters to 12 of the largest health plans and trade associations representing employer-sponsored health plans requesting information on how they plan to respond to the court decision.

“We are very concerned that the decision will unnecessarily cause confusion, force consumers to pay out-of-pocket, and result in patients forgoing preventive services screenings and treatment altogether,” the committee leaders said.

The Blue Cross Blue Shield Association said in a statement to Bloomberg Law: “All health plans will need to make decisions about how to handle coverage for the USPSTF recommendations that were issued after March 23, 2010.

“BCBS companies are encouraging members to continue accessing these services and will assess how best to navigate the post-ACA preventive service mandate to ensure equitable, affordable health care.”