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What Preventive Care Services Really Means

October 8, 2019

Recently we’ve been having a lot of friendly conversations about preventive care. The Trump Administration issued new preventive care guidelines for qualified high deductible health plans in July, and this topic has come up regularly ever since. Most people seem to want to know more about the federal definition of preventive care services, including what it is, who has to follow it, and why? A few others seem to be confused about whether or not it is ever linguistically appropriate to say preventative care, rather than preventive care. So we’re breaking it all down for you.

Over the years, preventive care has gotten a little more complicated than “an apple a day keeps the doctor away.” When it comes to health insurance, federal rules require coverage of many preventive care services without cost-sharing. So, lots of consumers consider it to be a “free” benefit, and they all want to know what kind of care they can get without incurring out-of-pocket costs.

The short answer is that the scope of preventive care benefits a person can get on a first-dollar basis depends on their type of health insurance policy. The Affordable Care Act (ACA) requires all health plans sold after March 23, 2010, (aka non-grandfathered plans) to cover certain preventive care services without cost-sharing. The list of services that must be covered stems from the current recommendations of four expert medical and scientific bodies. These are the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP), the Health Resources and Services Administration’s (HRSA’s) Bright Futures Project, and HRSA and the Institute of Medicine’s (IOM) committee on women’s clinical preventive services.

All non-grandfathered health plans must review these guidelines annually when determining benefit designs. When a new recommendation comes out, each health plan must cover it beginning with the next plan year, unless the federal Department of Health and Human Services issues guidance with a different timeframe due to a safety concern. The federal government doesn’t keep an updated list of all of these recommendations in one place, but the Kaiser Family Foundation does.

Beyond that broad requirement, there are other federal preventive care rules. However, they only apply to people with one specific type of health plan—a qualified high deductible health plan (HDHP) that pairs with a Health Savings Account (HSA). HDHPs predate the ACA. According to the 2003 federal law that created them, to legally pair with an HSA, HDHPs must subject all benefits to a minimum deductible, except for preventive care. All of the preventive care services on the ACA list are part of the definition of preventive care used for HDHP purposes. However, the law states that the Secretary of the Treasury is allowed to specify other preventive care services that HDHPs can cover before applying a deductible too. So people with HDHP coverage may appear to get more “free” services from their health plan than people with other types of coverage.

The Treasury Department spells out and amends its definition of preventive care for HDHPs in Notice 2004-23, Notice 2004-50, and Notice 2013-57. (These notices also include lots of other details about HDHPs and HSAs.) Notice 2018-12 explains that male sterilization or male contraceptives do not meet the IRS’s definition of preventive care for HDHP purposes.

Most recently, on July 17, 2019, the Treasury Department issued Notice  2019-45-45, which expands the list of preventive care benefits that an HDHP may cover before the application of a deductible even further. Previously, the Treasury Department excluded any medical care considered treatment from the list of preventive care services for HDHP purposes. Now HDHP plans may treat some specific procedures and prescriptions as preventive care for people who suffer from certain chronic diseases. These services can be covered before the deductible applies, but they don’t necessarily have to be “free” for participants.

This latest notice is the one that has sparked all of the questions, probably because people are eager for more “free” preventive care benefits. However, the new guidance does not apply to anyone but HDHP issuers and plan participants. People who do not have an HDHP are not affected by any of these additional IRS notices – they only apply to HDHPs. Even if a consumer is in a HDHP, that doesn’t mean they automatically get to take advantage of the new Trump Administration guidance. Ultimately, it will depend if the sponsor of their health plan decides to implement it.  The choice is really in the hands of the insurance carrier (for fully-insured plans) or the employer (for self-funded plans).

Finally, for those wondering whether you say preventive care or preventative care, the ACA, and all federal rules and code sections use the term preventive care. We also like to use the term preventive care. In the past, we may have even been slightly judgmental about people who said it differently. However, in the interest of humility, we checked, and the Merriam-Webster Dictionary prepared a ruling about this controversy, noting “There is no difference between preventive and preventative. They are both adjectives that mean ‘used to stop something bad from happening.'” So, it doesn’t matter if you say preventive care or preventative care. Live and learn.