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Health plans and insurance policies may no longer be required to cover the full cost of preventive care that carries an A or B rating by the U.S. Preventive Services Task Force (USPSTF), following a recent ruling by a federal district court in Texas.
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- The decision will almost certainly be appealed to the Fifth Circuit Court of Appeals, and the ruling may be stayed pending a determination on appeal.
- The ruling leaves intact the preventive care requirements that are based on guidelines maintained by the Prevention and Advisory Committee on Immunization Practices of the Centers for Disease Control (which include, for example, COVID-19 vaccinations).
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Health plans and insurers may wish to proceed cautiously in responding to this decision and watch for further developments on this case and additional guidance on its effect, if any, on matters such as the scope of preventive care that a high-deductible health plan may offer on pre-deductible basis.
A federal district court in Texas has invalidated and enjoined actions by federal agencies on and after March 23, 2010—when the Affordable Care Act (ACA) was enacted—to implement the ACA requirement that health plans and insurance policies cover the full cost of in-network preventive care that carries an A or B rating by the USPSTF. The court’s ruling broadly applies its earlier decision finding the ACA’s delegation of authority to the USPSTF violated the Appointments Clause of the U.S. Constitution.
The USPSTF issues recommendations on a range of preventive services, including breast cancer screenings, BRCA-related genetic testing, colorectal cancer screenings, and statin prescriptions to prevent cardiovascular disease. Health plan sponsors and insurers may choose to take a cautious approach in evaluating how the court’s decision affects coverage under their plans for various reasons, including:
- The decision will almost certainly be appealed to the Fifth Circuit Court of Appeals, and the ruling may be stayed pending a determination on appeal.
- The ruling formally applies to actions taken on or after March 23, 2010, which means that recommendations in effect prior to that date may continue to apply.
- The ruling leaves intact the preventive care requirements that are based on guidelines maintained by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (which include, for example, COVID-19 vaccinations) and the Health Resources and Services Administration (which include various guidelines pertaining to children, adolescents, and women, including contraception).
- Although used as a measure for ACA purposes, the recommendations made by the USPSTF are generally intended to provide guidance on sound medical practice. Plan sponsors may wish to consider the extent to which continued coverage for the screenings and other preventive measures that carry an A or B USPSTF recommendation may improve the health of plan members and produce a net cost-savings for the plan and plan sponsor.
As is often the case, it will be worth watching for further developments on this case and possible guidance on the decision’s effect, if any, on other matters, such as the scope of preventive care that a high-deductible health plan may offer on pre-deductible basis.