Will a court decision change preventive care coverage? 

The latest legal battle over the Affordable Care Act (ACA) is putting coverage of preventive services – vaccines, screening tests, drugs and services – into question. This Kaiser Health News article provides a good explainer for benefits professionals who might have to field questions from their C-suite and employees. Like other ACA cases, this one will probably take years to decide, so changes to preventive care benefits aren’t likely for 2023 or even for 2024. This should be welcome news, given most employers have already finalized their medical plan design and pricing for 2023.

If preventive care requirements were repealed

Prior to the ACA, many employer health plan sponsors, especially in larger organizations, encouraged the use of preventive care with generous coverage provisions. Annual physical exams were typically covered pre-deductible at 100%, sometimes by waiving cost-sharing up front and sometimes by reimbursing the out-of-pocket expense after the visit. Annual well-woman exams were almost always covered at 100%. On the other hand, contraceptives generally were subject to the pharmacy benefit design, resulting in out-of-pocket expense for plan members. The same was true for PrEP (for HIV prevention) when these drugs were first introduced; free coverage was required beginning in 2021. Further, smaller group plans and individual policies were less likely to provide access to various preventive services at no cost to members.

The ACA requirements generally eliminated these inconsistencies. A recent estimate from the U.S. Department of Health and Human Services found that more than 150 million people with insurance had access to free preventive care in 2020.  According to a literature review conducted by members of the University of Michigan’s Center for Value-Based Insurance Design concluded that cost-sharing elimination leads to increased use of preventive services, and that those who are financially vulnerable appear to benefit the most.

If allowed to make changes, some employers might revert back to pre-ACA coverage levels, but it’s likely that most large employers would not. Generous benefits for preventive care already were common before the ACA, and employer commitment to workforce health and wellness has only grown in recent years. It’s also difficult to “take back” a popular benefit like free preventive care. We’ll continue to track this potentially impactful court case and keep you apprised of developments.