Last week a Federal Judge in Texas struck down a key provision of the Affordable Care Act (ACA) preventive care requirement. The decision invalidates on a nationwide basis zero cost-sharing coverage requirements of certain preventive care items and services. It is expected that the federal agencies will quickly act to “stay” this decision, pending appeal, so that these impacted preventive services can continue nationwide. The practical impact of the ruling remains to be seen, although insurers may opt to continue to cover such services if they choose and self-funded plan sponsors could opt to do the same.
Limits on ACA Preventive Care Coverage The ACA requires most health plans to cover a set of preventive services without imposing cost-sharing requirements when the services are provided by in network providers. Among these are evidence-based items or services that have, in effect, a rating of “A” or “B” in the current recommendations of the U.S. Preventive Services Task Force (USPSTF). The decision invalidates the requirement to cover these A or B services without cost-sharing, and also ordered that the requirement to cover PrEP (a medication taken to prevent HIV contraction) specifically violates rights under the Religious Freedom Restoration Act.
The ruling does not impact all ACA preventive service requirements. Specifically, other preventive care services that must be covered, which were not the subject of the ruling, include:
For children, adolescents and adults, immunizations included on the CDC’s immunization schedules;
For infants, children and adolescents, evidence-informed preventive care and screenings provided for in the Health Resources and Services Administration (HRSA) guidelines; and
For women, evidence-informed preventive care and screening provided in guidelines supported by HRSA, including the contraceptive requirements.
Ruling Impact In the short term, the ruling appears unlikely to have an immediate impact on most plans and issuers. While plans may not be required to provide certain types of preventive care services without cost sharing pursuant to the ruling, many plans are expected to continue to provide this coverage. Insured plans may also need to continue to comply with state imposed preventive care requirements. If the decision ultimately remains intact, plans and issuers could have significantly more flexibility in the manner in which they cover certain preventive services, absent congressional action to the contrary.
We are tracking this case closely and expect the federal government to appeal immediately, and it is possible this case has the potential to ultimately reach the U.S. Supreme Court. This is a developing matter and so we will provide alerts and updates as new information becomes available. Please contact your Conner Strong & Buckelew account representative toll-free at 1-877-861-3220 with any questions. For a complete list of Legislative Updates issued by Conner Strong & Buckelew, visit our online Resource Center.