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New Preventive Services Under the Affordable Care Act

Employee Benefits Alert
December 4, 2014

The Affordable Care Act (ACA) requires non-grandfathered group health plans to provide benefits for items or services recommended by the U.S. Preventive Services Task Force (USPSTF). These benefits must be provided without member cost sharing. The USPSTF is an independent group of national experts in prevention and evidence-based medicine comprised of 16 volunteer members who come from the fields of preventive medicine and primary care, including internal medicine, family medicine, pediatrics, behavioral health, obstetrics/gynecology, and nursing. The USPSTF-recommended preventive services benefits must be provided as of the first day of the plan year that begins on or after the date that is one year after the date the recommendation is issued. 

Recent Guidance Related to Tobacco Use

In April 2009, the USPSTF recommended that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. In recently issued FAQ guidance, the agencies responsible for enforcing the ACA (the Departments of Health and Human Services, Labor, and the Treasury) stated that a group health plan will be in compliance with the requirement to cover tobacco use counseling and interventions, if the plan or issuer covers screening for tobacco use and, for those who use tobacco products, at least two tobacco cessation attempts per year. For this purpose, covering a cessation attempt includes coverage for four tobacco cessation counseling sessions of at least 10 minutes each (including telephone counseling, group counseling, and individual counseling) without prior authorization; and all Food and Drug Administration-approved tobacco cessation medications (including both prescription and over-the-counter medications) for a 90-day treatment regimen when prescribed by a health care provider without prior authorization.

The USPSTF publishes a matrix that includes the USPSTF recommendations issued in 2013 and 2014. As noted, the recommended preventive services benefits must be provided as of the first day of the plan year that begins on or after the date that is one year after the date the recommendation is issued. Plan sponsors should contact their insurers (or third-party administrators) to confirm that these services get implemented in a timely manner and communicated to plan participants.