Remaining ACA compliant is essential for individual, employer group health plans and association health plans. One crucial aspect to consider regarding compliance with the Affordable Care Act (ACA) is the inclusion of preventive services. The question arises: are preventive services required for both individual and employer groups to be ACA compliant, and do these requirements extend to group health plans?
Preventive Services and ACA Compliance:
The ACA recognizes the importance of preventive care and promotes access to preventive services as a key component of comprehensive health coverage. To ensure individuals have access to necessary preventive care without cost-sharing, the ACA mandates coverage of certain preventive services without imposing deductibles, copayments, or coinsurance.
Requirement for Small and Large Employer Groups:
Employer group health plans, both small and large, must comply with the ACA requirement of providing coverage for preventive services without cost-sharing. However, there is a distinction in the specific preventive services that must be covered:
- Small Group Health Plans: Small group health plans, typically covering 1-50 employees, must provide coverage for preventive services recommended by the United States Preventive Services Task Force (USPSTF) without any cost-sharing. This requirement applies to all preventive services that have an “A” or “B” rating from the USPSTF.
- Large Employer Group Health Plans: Large employer group health plans, typically covering 51 employees or more, must also provide coverage for preventive services recommended by the USPSTF without cost-sharing. However, they must additionally cover preventive services for women recommended by the Health Resources and Services Administration (HRSA), based on guidelines developed by HRSA.
Coverage for 100% Wellness and Preventive Services:
The ACA requires that certain preventive services be covered with no cost-sharing. This applies to individual ACA plans and extends to employer group health plans, including small and large groups. The coverage of wellness and preventive services without cost-sharing includes a range of screenings, immunizations, counseling services, and preventive medications.
Remaining ACA Compliant:
To ensure ACA compliance, employer group health plans and association health plans should consider the following:
- Understand the Requirement: Employers and associations should have a clear understanding of the ACA’s preventive services requirement, including the specific services that must be covered without cost-sharing.
- Check Recommended Guidelines: Employers and associations should refer to the recommendations of the USPSTF and HRSA for the list of specific preventive services that must be covered.
- Review Plan Documents: Employers and associations should review their plan documents, including insurance contracts or administrative agreements, to ensure that coverage for preventive services is included without cost-sharing.
- Educate Employees: It is important to inform plan participants about the availability of preventive services without cost-sharing. Employers and associations should communicate the importance of accessing preventive care as a part of a comprehensive health plan.
- Consult with Insurance Carriers: Employers and associations should consult with their insurance carriers or third-party administrators to ensure compliance with the ACA’s preventive services requirement.
Staying diligent and proactive in providing coverage for preventive services without cost-sharing helps employer and association health plans maintain ACA compliance while promoting the well-being of plan participants. Consult with an expert, such as Enrollment First, Inc., to ensure compliance in a health plan offering.
Sources:
[1] ACA Preventive Services: https://www.healthcare.gov/coverage/preventive-care-children/
[2] Small Business Health Options Program (SHOP) Marketplace: https://www.healthcare.gov/small-businesses/employers/coverage/
[3] Healthcare.gov: Preventive Services Covered by Private Health Plans: https://www.healthcare.gov/coverage/preventive-services-adults/
[4] Regulations.gov – Final Rules on Preventive Services Coverage: https://www.regulations.gov/document?D=EBSA-2018-0009-6252
[5] United States Preventive Services Task Force: https://www.uspreventiveservicestaskforce.org/recommendations.htm
[6] Health Resources and Services Administration: https://www.hrsa.gov/womens-guidelines/index.html