Downgraded Preventive Services

The federal Departments of Health and Human Services, Labor and the Treasury have released final regulations that address coverage and cost sharing for preventive services that are downgraded by the U.S. Preventive Services Task Force.

The task force assigns each service a letter grade based on the strength of the evidence and the balance of benefits and harms of a preventive service. For example, a service with an A or a B is recommended by the Task Force. By assigning a D, the Task Force is recommending against the service and discouraging its use.

As part of the final regulations, the departments clarified that when a recommendation or guideline for preventive services from the task force is downgraded in the middle of a plan year, generally group health plans and insurers must continue to cover the services without cost sharing through the end of the plan year, even if the recommendation or guideline changes or is eliminated during the plan or policy year.

However, there is no requirement under the final regulations to cover certain items and services through the last day of the plan or policy year if, during a plan or policy year:

• an A or B recommendation or guideline of the task force that was in effect on the first day of a plan or policy year is downgraded to a D rating (meaning the task force has determined that there is strong evidence that there is no net benefit, or that the harms outweigh the benefits, and therefore discourages the use of this service), or
• any item or service associated with any preventive service recommendation or guideline specified in federal regulations that was in effect on the first day of a plan or policy year is the subject of a safety recall or is otherwise determined to pose a significant safety concern by a federal agency authorized to regulate that item or service.

Other requirements of federal or state law may apply in connection with ceasing to provide coverage or changing cost-sharing requirements for any item or service. For example, if a group health plan or issuer makes any material modification in any of the term of the plan or coverage involved that would affect the content of the Summary of Benefits and Coverage (SBC), which is not reflected in the most recently provided SBC, and that occurs other than in connection with a renewal or reissuance of coverage, the plan or issuer must provide notice of the modification to enrollees not later than 60 days prior to the date on which the notification will become effective.

For more information on preventive health services mandated under the Patient Protection and Affordable Care Act, follow this link.