When Must a Non-Grandfather Group Health Plan Comply with Changes to Preventative Health Services Requirement?

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

Answer: Plan sponsors and advisors 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. In addition, state laws may impose additional requirements on insurers—such requirements are not superseded by health care reform.

HHS’s website 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, the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and the Health Resources and Services Administration. Nevertheless, you should also monitor the lists on the websites of these organization.

Since 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 continue to provide coverage through the end of the plan year in which the recommendation was discontinued, unless the recommendation is downgraded to a “D” level or is found to be unsafe. For example, 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 found to be unsafe, or downgraded to a “D” level, your plan would not be obligated to cover that item or service through the end of the year.

For more information, see EBIA’s Health Care Reform manual at Section XII.C.2 (“General Rules Regarding Required Coverage of Preventive Services”). See also EBIA’s Group Health Plan Mandates manual at Section XIV.C (“Required Preventive Health Services Coverage”) and EBIA’s Self-Insured Health Plans manual at Section XIII.C.1 (“Preventive Health Services”).

Sources: Thomson Reuters EBIA