The federal Patient Protection and Affordable Care Act requires health plans to cover the following preventive services with no cost sharing:
Preventive services covered by this requirement include:
State law requires health plans issued or renewed on or after June 7, 2018, to provide coverage without cost sharing for the same preventive services required to be covered under 42 U.S.C. Sec. 300gg-13, the provision summarized above, and any federal rules or guidance in effect on December 31, 2016, implementing the law. The Insurance Commissioner (Commissioner) must enforce this requirement consistent with federal rules, guidance, and case law in effect on December 31, 2016.
A nongrandfathered health plan issued or renewed on or after 90 days following the end of the 2024 legislative session must provide coverage without cost sharing, except as provided below, for the following preventive services as the recommendations or guidelines existed on January 8, 2024:
For purposes of recommended immunizations, a recommendation from the ACIP is considered in effect after the recommendation has been adopted by the Director of the CDC, and a recommendation is considered to be for routine use if the recommendation is listed on the immunization schedules of the CDC. The reference to the federal law citation is removed.
A nongrandfathered health plan must provide coverage for the required preventive services consistent with federal rules and guidance related to coverage of preventive services in effect on January 8, 2024. A nongrandfathered health plan is no longer required to provide coverage for any items or services specified in any recommendation or guideline, if the recommendation or guideline is revised by the federal recommending entities to no longer include the preventive item or service. A nongrandfathered health plan must provide coverage for the required preventive services for plan years that begin on or after the date that is one year after the date the recommendation or guideline is issued. Annually, a health carrier must determine whether any additional items or services must be covered without cost sharing or whether any items or services are no longer required to be covered, which must be included in the health plan filings submitted to the Commissioner.
The prohibition on imposing cost sharing for preventive services is limited to when the services are provided by an in-network provider. If a plan does not have in its network a provider who can provide a preventive item or service, the plan must cover the item or service when performed by an out-of-network provider and not impose cost sharing for the item or service. If any portion of the federal law is found invalid for high deductible health plans with a health savings account, the health carrier may apply cost sharing to the services that have been invalidated at the minimum level necessary to preserve the enrollee's ability to claim tax-exempt contributions and withdrawals from the enrollee's health savings account.
A health carrier may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for an item or service to the extent not specified in the relevant recommendation or guideline, federal rules and guidance related to the coverage of preventive care in effect on January 8, 2024, and Commissioner rules. The Commissioner must enforce these requirements consistent with federal rules and guidance in effect on January 8, 2024.
The Commissioner is authorized to adopt rules necessary to implement these requirements consistent with federal statutes, rules, and guidance in effect on January 8, 2024. The Commissioner may also adopt rules related to any future preventive services recommendations or guidelines from the USPSTF, the ACIP, and the HRSA as described above or related rules or guidance.
The Senate amendment makes technical corrections to the names of several federal entities listed in the bill.
(In support) This bill is meant to provide flexibility as new services are recommended. It is important for public health to have access to these services in Washington. This bill provides helpful clarity in light of the current litigation, which invalidated portions of the federal law, though the decision has been stayed. Plans already cover these services and any new recommendations under federal law.
In 2018 the Legislature passed a bill that embedded a number of the Affordable Care Act (ACA) provisions in state law. This included a provision that locked in the ACA's preventive services requirements as they existed in 2016, but there have been a number of new recommendations since 2016, including colorectal cancer screenings and lung cancer screenings for certain groups, blood pressure screenings, and pre-exposure prophylaxis HIV medication.
Washingtonians have come to rely on these services and preventive services are one of the most basic things. Cost sharing is often the biggest barrier for individuals seeking care and barriers should be removed. This bill provides a guarantee and takes an important step by ensuring access to care.
(Opposed) None.
Representative Marcus Riccelli, prime sponsor; Jane Beyer, Office of the Insurance Commissioner; Stephanie Simpson, Bleeding Disorder Foundation of Washington; Jennifer Ziegler, Association of Washington Health Care Plans; and Emily Brice, Northwest Health Law Advocates.