As you probably know, under the Affordable Care Act (ACA), preventive care is covered without being subject to deductibles or coinsurance. The idea was to remove financial barriers that might discourage people from getting preventive services. But a gap in the program left out consideration of preventive services required by people with a chronic condition.
For example, if a person who did not have diabetes went to the doctor and had a screening blood test done to see if they had diabetes, the visit and the test would be fully covered without a deductible or coinsurance. However, if a person with known diabetes went to their physician and had the same test done as part of the regular follow-up care for their condition, the visit would be subject to their deductible and coinsurance.
Interestingly, responsibility for many of the regulations that apply to the ACA falls under the IRS (since they are related to the taxability of health benefits). A July 2019 IRS update expands coverage for preventive care for those with chronic conditions so that these preventive services will now no longer be subject to deductibles or coinsurance.
It is well known that many people with chronic illnesses do not receive needed preventive care for their conditions because of the cost they have to bear for these services. This new regulation should help reduce this barrier to care and help those with chronic needs better care for themselves.
While this change applies to fully insured plans, what does it mean to self-insured employers? With many companies defining their 2020 benefit programs at this time of year, we think employers would be wise to examine their coverage for preventive care and adopt this coverage approach within their plan design. Evidence-based preventive care is always cost-effective and contributes to better health and well-being for employees and their family members.
To learn more about this update, read the IRS notice here. If you have questions about these changes or would like guidance defining the parameters for preventive care coverage, contact Health Advocate. Our clinical team will be happy to help.