As a business owner, there are a number of different laws and pieces of legislation that you need to remain compliant with in order for your business to continue running. Some of these laws or the details of the laws therein may be very well known to you and to others within your organization, but others may be much more complicated and less understood by you or others within your organization. The Affordable Care Act, for example, has some compliance rules that are relatively easy to follow and understand, the most notable being the requirement of certain large employers to offer health insurance. But understanding what lies beneath just the surface level of different laws like this can be crucial in maintaining compliance and preventing future stress or potential legal problems.
At Payday HCM, we understand the importance of remaining compliant. We are always receiving questions from current clients about different rules and regulations, whether they’ve just been enacted or they’ve been around for years. Inevitably, you’re going to run into something that you have questions about and need clarification about. Recently, the Supreme Court issued a decision on a case regarding preventive care within the ACA, more specifically on the U.S. Preventive Services Task Force and its ability to make preventive services recommendations. It’s possible that you heard about this decision and were wondering what the requirements are for preventive care under the ACA following this decision.
Well, in this article, we’ll be going over what preventive care is and its role within the ACA. We’ll briefly go over what preventive care is before diving deeper into the details of what the requirements surrounding preventive care are within the ACA. Finally, we’ll break down what all of this means for your business and how it affects the kinds of health insurance plans you offer to your employees. By the end of this article, you’ll have all the information you need to be an expert on preventive care and its role within the ACA.
In this article, you will learn:
- What is Preventive Care?
- Preventive Services and the ACA
- How Preventive Care and the ACA Impact Your Business
What is Preventive Care?
To start, we’ll first break down what preventive care is and the kinds of things that fit under the banner of preventive services.
Preventive Care
Generally, when you hear the words “preventive care,” they are used in reference to a particular set of screenings, tests, or check-ups that help to prevent certain diseases or medical problems. Preventive care is aimed at catching things before they develop into a larger problem, generally focusing on services that take place prior to known symptoms forming.
The distinction between preventive care and diagnostic care is an important one because it affects what services actually fall under the preventive care banner. Generally, preventive care comes first and if anything arises from the preventive care, the subsequent actions are considered diagnostic care (when looking for something specific after a set of tests or known symptoms).
Preventive Services
You may hear the words “preventive care” and “preventive services” used somewhat interchangeably. Generally speaking, they are referring to the same thing, although preventive care is referring moreso to the idea of utilizing preventive services to detect possible diseases or medical problems whereas preventive services is the actual screenings, tests, or check-ins.
The types of preventive services include things like type 2 diabetes screenings, a variety of cancer assessments and screenings, and a range of immunizations. Preventive care and utilization of preventive services are generally viewed as helpful in reducing the mortality rates of certain conditions: early screenings of certain cancers and chronic diseases can lower mortality rates as much as 15 to 20 percent, according to the National Library of Medicine.
Preventive Services and the ACA
Now that we have a better understanding of what preventive care is, we can dive deeper into its role within the ACA.
What Are the ACA’s Preventive Care Requirements?
Under Section 42 of the ACA, all group and individual health insurance plans must cover preventive services without imposing any cost-sharing requirements on the patient, including co-payments, deductibles, or co-insurance. The only exception to this rule would be any “grandfathered” plans, or health plans that were already in place when the ACA was enacted.
The types of services that are covered within the preventive care provision are determined by recommendations from four different medical and scientific bodies: the U.S. Preventive Services Task Force (USPSTF), the Health Resources and Services Administration’s (HRSA’s) Bright Futures Project, the Advisory Committee on Immunization Practices (ACIP), and the HRSA-sponsored Women’s Preventive Services Initiative (WPSI).
Preventive Services Covered by the ACA
The ACA outlines the requirements for preventive services by breaking them up into a few different categories, mainly for adults, children, and certain preventive services for women based on recommendations by the WPSI. The list of preventive services for all adults includes:
- Blood pressure screening
- Type 2 diabetes screening
- HIV screening
- Immunizations
- Lung cancer screening
The list includes a large number of other screenings, medications, and counseling. The preventive service requirements for children and the preventive service requirements for women include different screenings, tests, immunizations, and regular check-ups specific to them.
How Preventive Care and the ACA Impact Your Business
Now that we have a good overview of what preventive care is and its requirements within the ACA, we can dive deeper into how these requirements affect your business.
Group Health Insurance and Preventive Care
Generally speaking, if you are required to offer health insurance to your employees under the ACA’s requirements, you will also be required to offer coverage for preventive care—this is something that’s offered through the health insurance plan, though, not by the employer. Any group health insurance plan should offer the appropriate preventive care coverage, but you can always ask to be certain.
The one thing to note in regards to preventive care that can be helpful for businesses to let employees know is that preventive services are only covered for in-network providers. This doesn’t affect employers that offer a closed-network plan, but employers offering an open-network or open-access plan should take note and communicate appropriately with their employees.
Employers that are required to offer health insurance to their employees under the ACA are referred to as applicable large employers. If you have 50 or more full-time employees within a calendar year, you must offer your employees a health insurance plan that offers minimum essential coverage and is affordable (covering 60 percent of health spending and not exceeding 9.12 percent of total household income).
Grandfathered Plans and Preventive Care
Although only 13 percent of workers reported being enrolled in a grandfathered health insurance plan as of 2019, it’s still possible that your business may offer a grandfathered plan that is not required to meet the ACA’s preventive care requirements. Employers can only continue enrolling employees in grandfathered plans so long as consecutive enrollment has been maintained.
While there’s no requirement to switch over to a non-grandfathered plan or to transition your organization to a new plan that is subject to the requirements, it still could be a good consideration as it will help to ensure your insurance plan is not only up to date, but also compliant with all current laws and regulations while also offering your employees wider coverage options.
Caring For Your Employees With Preventive Care
As we said at the start of this article, being a business owner means not only running your business, but also keeping up with any new or already existing pieces of legislation that may affect your business. Ensuring that you are compliant with any sort of laws or regulations can be crucial in ensuring that business operations continue as normal and that your business is operating as efficiently as possible. When it comes to preventive care and the ACA, an added benefit on top of compliance is being able to offer your employees a more comprehensive health insurance plan, which can improve morale and demonstrate your appreciation for them. With the information provided in this article, you’ll have what you need to ensure your health insurance plan is both compliant and comprehensive.
There are a number of questions you’ll need to ask and find the answers to when creating your employee benefits package. When it comes to health insurance, you want to ensure that you’re not only offering a comprehensive insurance plan that benefits all of your employees, but you also need to remain compliant with all the necessary laws—and, preferably, keep it affordable. At this point, you arrive at the question of whether to go with a self-insured or fully-insured plan. Check out our article for the differences between a self-insured and a fully-insured health insurance plan so you can make the best decision for your business.
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