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The agencies released informal guidance that adds to the list of items that must be covered with no cost-sharing as preventive; explains a plan sponsor’s responsibility for ensuring that preventive care is properly coded and covered; and clarifies the reconstructive coverage that must be provided under the Women’s Health & Cancer Rights Act (WHCRA).ÌýThe FAQs, Part 68 can be found and a summary is below.

• Coverage of Pre-Exposure Prophylaxis (PrEP)Ìý
  • For plan years beginning on or after Sept. 1, 2024, non-grandfathered group health plans must provide coverage with no cost-sharing for three FDA-approvedÌýPrEPÌýformulations (two oral and one injectable), as well as specified baseline and monitoring,Ìýand are not permitted to use medical management techniques to direct individuals prescribedÌýPrEPÌýto utilize one formulation over another. The latest recommendationÌýapplies to sexually active adults and adolescents weighing at least 35 kg (77 lb.) who do not have HIV and are at increased risk of HIV.ÌýÌý

• Coding and Coverage for Recommended Preventive CareÌý
  • Medical items or services coded as preventive care in accordance with PHSAÌý§2713 (or any item or service that is integral to the furnishing of a recommended preventive item or service), must be covered without cost-sharing by non-grandfathered group health plans, unless the plan sponsor has individualized information that establishes that the item or service was not preventive care.
    
    If a medical item or service is coded as preventive, but the plan sponsor has information suggesting otherwise, the plan sponsor must ask the claimant and the provider for further information prior to imposing cost-sharing or denying the claim.
    
    Many medical items and services could potentially be for preventive care as well as for non-preventive care, and there have been many complaints of full coverage not being made available for preventive care. To address this, guidance recommends that plan sponsors regularly review the latest preventive care recommendations and published industry standards and thenÌýmodify their coding guidelines, claims processing systems, and other relevant internal protocols if needed to ensure that claims for preventive care are coded appropriately and covered without cost-sharing.
    
    There is also an expectation that plan sponsors willÌýeducate their network providers and provide clear guidance on proper codes and modifiers toÌýidentify an item or service as preventive care. To further illustrate the requirements and expectations, the guidance provides several examples forÌýcommon claims scenarios.Ìý
• WHCRA GuidanceÌý
  • ÌýFor any group health plans that provide coverage for mastectomies, the plan must also provide coverage forÌýall stages of reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, prostheses, and treatment of physical complications of the mastectomy, including lymphedema.
    
    The FAQ guidance clarifies that this coverage requirement includesÌýcoverage for chest wall reconstruction with aesthetic flat closure, if elected by the patient in consultation with the attending physician in connection with a mastectomy.
    
    NOTE: This coverage requirement is not preventive and does not have to be provided with no cost-sharing, but instead should be covered subject to applicable plan cost-sharing (e.g., deductible and co-insurance).Ìý

Employer/Plan Sponsor Action

Self-funded group health plan sponsors should work with their TPAs to ensure proper cost and coding measures are applied as described above starting with the plan year on or renewing after 9/1/24.

Fully insured group health plan sponsors must rely on their carriers to implement the changes.

Contact your IMA broker representative with any questions.

IMA will continue to monitor regulator guidance and offer meaningful, practical, timely information. This material should not be considered as a substitute for legal, tax and/or actuarial advice. Contact the appropriate professional counsel for such matters. These materials are not exhaustive and are subject to possible changes in applicable laws, rules, and regulations and their interpretations.

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