October means..

a little bit of cleanup and planning. This includes our health. Read this week for a quick overview of coverage for screenings and immunizations!

Reading time: 3-4 mins

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Patients often inquire about the preventive tests they should consider, particularly as October approaches. Wondering why?

The answer is quite straightforward: deductibles.

The majority of patients are enrolled in insurance plans that involve some form of cost-sharing, whether it's a deductible for out-of-network services, procedures, pharmacy benefits, or various other aspects.

Therefore, it's not surprising that patients often find themselves bewildered and anxious as the year-end approaches, especially when it comes to understanding coverage for routine screenings.

To help clarify things, here's a brief overview of key preventive services that are covered without any cost-sharing requirements.

What screenings are covered without cost-sharing at this time?

Level A or B Recommendations of USPSTF are required to be covered, regardless of cost sharing, all year round, by all insurers. These include screenings for:

• Depression and/or Anxiety

• Type II DM

• Obesity

• Sexually Transmitted Infections

• Hepatitis C and B

• Prenatal Tests

• PREP/PEP for HIV

• Cancers: Breast, Cervical, Colorectal, Lung

• Heart Disease

• Tobacco use

• Osteoporosis

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What Immunizations are covered without cost-sharing at this time?

Health plans must also provide coverage for immunizations that are recommended by the ACIP/CDC.

• COVID-19

• Influenza

• Meningitis

• Tetanus

• HPV

• Hepatitis A & B

• Measles, Mumps, Rubella,

• Pneumococcal

• Varicella

On Medicare: Inflation Reduction Act of 2022 allowed vaccines to be fully covered under Medicare prescription drug plans (Part D) and Medicaid, these include:

• COVID-19

• Influenza

• Pneumococcal

• Tetanus

• Varicella

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Will this change?

Over the past few years, there have been legal challenges regarding the coverage of preventive services under the ACA, with claims that covering USPSTF Level A or B services is unconstitutional. According to the KFF, the case of Braidwood Management v. Becerra involves Christian-owned businesses and six individuals in Texas who argue that:

1. The ACA's mandate for specific expert committees and a federal government agency to recommend covered preventive services is unconstitutional.

2. The requirement to cover pre-exposure prophylaxis (PrEP) infringes upon their religious rights.

On March 30, 2023, District Court Judge O’Connor issued a ruling in the case of Braidwood Management v. Becerra, which prohibits the government from mandating health plans to cover services recommended or updated by the U.S. Preventive Services Task Force (USPSTF) on or after March 23, 2010. It's important to note that this ruling doesn't impact USPSTF recommendations made before March 23, 2010, the requirement for plans to cover Women’s Preventive Services as recommended by the Health Resources and Services Administration (HRSA), or vaccines recommended by the CDC & ACIP. Additionally, the ruling cited that covering pre-exposure prophylaxis (PrEP) violates the religious protections and rights of the plaintiffs.

Subsequently, the federal government has appealed this decision to the United States Court of Appeals for the 5th Circuit. The 5th Circuit Court of Appeals has issued an administrative stay on District Court Judge O’Connor's ruling, allowing the federal government to continue enforcing the preventive services requirement. The 5th Circuit court is still deliberating on the Department of Justice’s motion for a stay pending appeal.

See KFF’s in-depth assessment of the positions and journey of this litigation.

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Final Thoughts

As of now, preventive services including immunizations are required to be covered. It's crucial for us to offer guidance to our patients and communities regarding the latest screening and immunization guidelines. The significance of vaccination in preventing public health crises and enhancing the overall well-being of our communities cannot be overstated. As we gear up our homes and gardens for the impending winter every October, we should also dedicate some effort to prepare our bodies for the year ahead. Because winter is coming!