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Biden Administration Makes Deal to Keep Preventative Health Coverage in Place During Legal Challenge

In response to the latest legal challenge to the ACA, the Biden Administration reached a deal to keep in place ACA rules requiring insurers to cover preventative care without cost sharing.

Earlier this year, a federal judge in Texas issued a ruling in Braidwood Mgmt. Inc. v. Becerra (Braidwood). The ruling stated that non-grandfathered group health plans and insurers no longer have to cover preventive services recommended by the United States Preventive Services Taskforce (USPSTF), a panel of experts in primary care and prevention, without cost sharing.

The Braidwood ruling also stated that employers with religious objections that sponsor health plans no longer have to cover PrEP HIV medications. Section 2713 of the Public Health Service Act (PHS) requires that non-grandfathered group health plans and health insurance issuers that offer non-grandfathered group or individual health insurance coverage provide benefits for and prohibit cost-sharing requirements to:

  • Evidence-based items or services that have a rating of “A” or “B” as currently recommended by the USPSTF except 2009 regulations regarding breast cancer screening, mammography, and prevention.
  • Immunizations for routine use in children, adolescents and adults that have a recommendation from the Advisory Committee on Immunization Practices of the CDC.
  • Evidence-informed care for infants, children and adolescents found in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA).
  • Preventive care and screening for women in a comprehensive guideline supported by the HRSA.

The plaintiffs in Braidwood claimed that the “Appointments” and “Vesting” clauses of the U.S. Constitution and the “nondelegation” doctrine bar the USPSTF and other groups from making recommendations. The federal court agreed and said all coverage requirements related to the “A” or “B” rating recommendations of the USPSTF are vacated.

The Biden Administration appealed the decision, which is currently under review by the Fifth Circuit Court of Appeals. The Administration also reached a deal to preserve the nationwide mandate requiring that the services recommended by USPSTF and PrEP HIV medications continue to be covered at no extra cost while the legal challenge is pending.

As a reminder, even if the decision is upheld on appeal, plan sponsors can still choose to cover these preventative services. It is also possible that Congress will respond to the decision by amending the law to require coverage of these services.

If you have questions about the decision and how it may impact your health plan, contact your OneDigital consultant.

For more coverage of compliance developments, check out our monthly news roundup: What We’re Watching: Employer Compliance Across Benefits, HR, and Retirement.