Affordable Care Act (ACA) – Changes to Preventive Care Coverage Requirements

This is an update of an article originally published in the Q4 2018 edition of WellInformed.

The Affordable Care Act (ACA) offers rights and protections to consumers and requires easy-to-understand coverage for all, including those with pre-existing conditions. A key provision of the ACA is the requirement that insurance plans cover recommended preventive services without any patient cost-sharing.1 Research indicates that evidenced-based preventive services save lives and improve health outcomes by:

  • Identifying health conditions earlier
  • Managing health conditions more effectively
  • Treating health conditions before they develop into more complicated, debilitating conditions.2

Early identification, accurate diagnosis, and effective treatment of health conditions reduces the economic burden of disease, and improves the length and quality of peoples’ lives. A recent publication by Kaiser reports that about 1 in 10 adults reported delaying or not receiving care due to cost.3 The ACA legislation is an attempt to alleviate cost barriers and provide more patients with access to preventive care services. It incorporates recommendations made by expert medical and scientific bodies to establish preventive services to patients at no cost.

In June 2019, the US Preventive Services Task Force (USPSTF) updated its recommendations to include the addition of pharmacologic therapy for pre-exposure prophylaxis (PrEP) to HIV. The recommendation applies to people that are not infected with HIV, but are at high risk for acquiring the disease. A systematic review determined that, in patients with an increased risk of HIV infection, PrEP with oral tenofovir disproxil fumarate monotherapy, or tenofovir disoproxil fumarate/emtricitabine (Truvada), was associated with a decreased risk of acquiring HIV infection compared with placebo or no PrEP, although effectiveness decreased with suboptimal adherence. Once-daily tenofovir disoproxil fumarate/emtricitabine is FDA approved for treatment of PrEP, whereas tenofovir disproxil fumarate monotherapy is not. This change will go into effect January 1, 2020.

In accordance with ACA HCR preventive service coverage requirements, WellDyneRx will add Truvada to the list of medications covered at a $0.00 cost-share to the patient beginning January 1, 2020. Patients must meet certain clinical criteria to receive the medication at a $0.00 cost-share.

References

  1. The Patient Protection and Affordable Care Act https://www.govinfo.gov/content/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
  2. Maciosek, Michael V. ‘Greater Use of Preventive Services in U.S. Health Care Could Save Lives at Little or No Cost.’ Health Affairs 29.9 (2010): 1656-660.
  3. Cox, C and Sawyer, B. (2018, January 17). How does cost affect access to care? Retrieved from https://www.healthsystemtracker.org.
  4. Guirguis-Blake, JM, Michael, YL, et.al. (2018). Interventions to Prevent Falls in Older Adults: Updated Evidence Report and Systemic Review for the US Preventive Services Task Force. JAMA. Retrieved from https://jamanetwork. com/journals/jama/fullarticle/2678103
  5. Chou R, Evans C, Hoverman A, et al. Preexposure prophylaxis for the prevention of HIV infection: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2019;321(22):2214-2230. Retrieved from https://jamanetwork.com/journals/jama/fullarticle/2735508

 


2019 Quarter Three WellInformed Table of Contents