On January 10, 2022, the Departments of Labor (DOL), Health and Human Services (HHS), and the Treasury (collectively, “the Departments”), released FAQs addressing requirements for non-grandfathered group health plans related to coverage of colonoscopies as required by the preventive care rules under the Affordable Care Act (ACA). The FAQs also announced the Departments’ investigation and enforcement efforts regarding noncompliance with the preventive care contraceptives mandate.

In addition, on January 11, 2022, HHS issued a press release outlining updates to comprehensive preventive care and screening guidelines specific for women and infants, children, and adolescents. As such, most group health plans and insurance carriers (insurers) will be required to provide coverage without cost sharing for the updated services, described further below.

Compliance Snapshot

  • Beginning on or after May 31, 2022, group health plans and insurers must provide coverage for services integral to preventive colorectal cancer screenings with a rating of “A” or “B” by the United States Preventative Services Task Force (USPSTF).
  • Coverage for all FDA-approved contraceptives is required (this is not a new requirement), and the DOL continues to investigate and enforce compliance with this mandate.
  • Group health plans and insurers are required to provide coverage without cost sharing of the new and updated services in the Women’s Preventative Services Guidelines and the Bright Futures Periodicity Schedule, effective for plan years beginning in 2023.

Background

Section 2713 of the Public Health Service Act (PHS), as added by the ACA, requires non-grandfathered group health plans and insurers offering non-grandfathered group health plans to provide certain preventative care without cost sharing (i.e., deductibles, copayments, and coinsurance), including items and services that have received an “A” or “B” rating by the USPSTF, as well as preventive care and screening for women, children, and infants as described by Health Resources and Services Administration (HRSA) guidelines.

New Preventive Coverage Requirements and Reminders

In the recent DOL FAQs, the Departments specifically address coverage regarding follow-up colonoscopies upon receiving a positive stool-based or direct visualization screening test, consistent with the USPSTF recommendations. For reference, USPSTF recommends (with an “A” rating) screening for colorectal cancer in all adults aged 50 to 75 and expanded this recommendation (with a “B” rating) in May 2021 to also include such screening for adults aged 45 to 49. The recommendations in May 2021 additionally provided that a follow-up colonoscopy should be performed in the event of an abnormal stool-based or direct visualization.

In light of the above, the DOL FAQs clarify that group health plans and insurers must cover a follow-up colonoscopy performed after a positive, non-invasive stool-based or direct visualization screening test for colon cancer without cost sharing for individuals covered by the USPSTF recommendations. In this instance, such colonoscopy is considered an integral part of the screening. This coverage, as well as screening for colorectal cancer for adults aged 45 to 49, must be provided for plan years beginning on or after May 31, 2022 (e.g., January 1, 2023 for calendar year plans). See Q7 and Q8 of the DOL FAQs for additional information.

The DOL FAQs, as a response to complaints and reports of potential violations of the contraceptive coverage requirement, also reiterate that all Food and Drug Administration (FDA)-approved contraceptives that are determined to be medically appropriate by an individual’s medical provider must be covered by group health plans and insurers (not exempt from the contraceptives mandate) without cost sharing. This holds true whether or not such contraceptives are specifically identified in the current FDA Birth Control Guide. The Departments caution employers, stating that they are actively investigating complaints and reports of noncompliance and that they may pursue enforcement or other corrective actions. Examples of violations include denying coverage for brand name contraceptives (even when medically appropriate as determined by a medical provider) and requiring individuals to fail first (e.g., step-therapy) before covering FDA-approved contraceptives deemed medically appropriate by a medical provider.

In addition, effective for plan years beginning in 2023, group health plans and insurers subject to preventive care requirements are required to provide coverage without cost sharing of the new and updated services in the Women’s Preventative Services Guidelines and the Bright Futures Periodicity Schedule; highlights include:

  • Double electric breast pumps as part of breastfeeding equipment;
  • Obesity counseling for women ages 40 to 60;
  • Universal suicide risk screening for ages 12 to 21 (added to the depression screening); and
  • New guidelines for assessing risks of cardiac arrest or death in ages 11-21 and Hepatitis B for newborn to age 21.

Employer Action

Employers should be aware of these updated coverage requirements and discuss with their carriers (if fully insured) or their third-party administrators (if self-insured/level funded) to ensure their plans are:

  • Compliant with the preventive care contraceptives mandate (if not exempt); and
  • Will be compliant with the expanded preventive care coverage requirements as described above, keeping in mind the applicable effective dates.

Additional Resources

Diane Cross — Diane is a Client Compliance Consultant for Sequoia, where she works with our clients to optimize and streamline benefits compliance. In her free time, Diane enjoys spending time with her family, live music, and cycling.