Coverage of preventive care services has been a cornerstone of health care since implementation of Section 2713 of the Public Health Service (PHS) Act, as added by the Affordable Care Act (ACA). The law requires non-grandfathered group health plans to cover specific preventive health services without cost-sharing (e.g., copayments, deductibles, or other out-of-pocket costs). These services are determined by recommendations from three key agencies—the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention, and the Health Resources and Services Administration (HRSA).
Updates to these recommendations are made to align with the latest medical research and public health priorities. These updates generally take effect beginning with the plan year that starts one year or later after a new recommendation is issued.
Calendar year plans must cover the following preventive care services without cost-sharing, effective January 1, 2025:1
- Poliovirus Vaccine (expanded coverage). Coverage for the vaccine has been expanded to include persons aged 18 and older who are known or suspected to be unvaccinated or incompletely vaccinated against polio.
- Anxiety Disorder Screenings (expanded coverage). Covered screenings for anxiety disorder have been expanded to include adults aged 64 and younger, including pregnant and postpartum individuals.
- Respiratory Syncytial Virus (RSV) Vaccine (new requirement). The vaccine must now be covered for:
- Adults aged 60 and older;2
- Infants up to eight months old who are entering their first RSV season, and for children between eight and 19 months who are at increased risk during their second RSV season; and
- Pregnant people between 32 and 36 weeks of gestation to protect infants from RSV-related lower respiratory tract infection.
- Mpox Vaccine (new requirement). The vaccine must now be covered for individuals aged 18 and older who are at increased risk for mpox.
Employer and Plan Sponsor Next Steps
If they haven’t done so already, employers and plan sponsors should confirm that their third-party administrators are prepared to cover these services as preventive care and should review plan and summary plan description language with their counsel to determine whether any amendments are necessary.
This blog was drafted by Natalie Miller and Alexandra Reveron, an attorney and a benefits analyst, respectively, in the Spencer Fane Overland Park, Kansas, office. For more information, visit spencerfane.com.
1 Non-calendar year plans must cover preventive care services for recommendations that were issued at least one year on or prior to the first day of the plan’s 2025 plan year.
2 Beginning with the 2026 plan year, the RSV vaccine recommendation for older adults was modified to apply only to adults aged 60 to 74 who are at increased risk and to all adults aged 75 and older.
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