Health Plans to Continue Offering Free Preventative Care Per New Ruling

2 minute read

On June 21, 2024, the 5th U.S. Circuit Court of Appeals ruled a key component of the Affordable Care Act's (ACA) preventive care mandate unconstitutional. The ruling applies only to a small group of individuals and businesses in Texas. This means that, for now, health plans and insurance issuers must continue providing first-dollar coverage for preventive health services, including screenings and medications. It’s expected that the U.S. Supreme Court may be asked to review the decision.

This decision impacts the requirement to cover a range of preventive healthcare services including screenings for colorectal, lung, and cervical cancers, medications for chronic conditions like cardiovascular disease, HPV screening, depression and anxiety assessments, as well as screenings for Hepatitis B and C viruses, all without any cost-sharing involved.

ACA’s Preventative Care Mandate

The Affordable Care Act mandates that non-grandfathered health plans and issuers must include a range of preventive services at no additional cost to the individual, when received from in-network providers. The recommended preventative care services covered by these requirements are:

• Evidence-based items or services with an A or B rating in recommendations of the U.S. Preventive Services Task Force (USPSTF);
• Immunizations for routine use in children, adolescents, and adults recommended by the Advisory Committee on Immunization Practices (ACIP);
• Evidence-informed preventive care and screenings in guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children, and adolescents; and
• Other evidence-informed preventive care and screenings in HRSA-supported guidelines for women.

Court Decisions

In March 2023, the U.S. District Court for the Northern District of Texas invalidated a key part of the ACA's preventive care mandate, citing constitutional violations in the appointment of USPSTF members. The Biden administration appealed to the 5th Circuit, which temporarily halted enforcement of the mandate for health plans and issuers. The 5th Circuit agreed on the appointment issue but limited relief to the plaintiffs, remanding other challenges back to the District Court for review.

Decision’s Impact

Due to this ruling, health plans and issuers must continue covering recommended preventive care without cost sharing, with only the plaintiffs exempt from a portion of the ACA's mandate. The future of the ACA's preventive care mandate is uncertain, prompting employers to stay updated on legal developments. Download the bulletin for more details.