SF3859

Purpose

Clarify and expand requirements so that health plans cover a broad set of preventive items and services without cost-sharing and to specify which immunizations and HIV-related measures are included. The bill ties coverage to nationally recognized guidelines and recommendations (e.g., USPSTF, ACIP, AAP) and sets up rules for how plans must administer these benefits, including annual reviews and allowed exceptions.

Main provisions (what the bill would do)

• Preventive items and services: Define these according to the Affordable Care Act and include items with an A or B rating from the USPSTF, recommendations from the ACIP (CDC), and schedules from the American Academy of Pediatrics (AAP). Also include items from the West Coast Health Alliance and comprehensive HRSA-guided guidelines for women, plus contraceptive methods per FDA guidelines.
• Immunizations for routine use: Require coverage of immunizations for routine use in infants, children, adolescents, and adults, without cost-sharing, as long as the recommendations are in effect.
• Coverage without cost-sharing: Health plans must cover these preventive items and services without a deductible, coinsurance, or copayment when provided by participating providers.
• Out-of-network care: Plans may exclude coverage or impose cost-sharing for preventive items or services delivered by out-of-network providers.
• Annual review: Health plans must annually determine whether to add or remove items or services from the list that must be covered without cost-sharing.
• Medical management: Plans may use reasonable medical management techniques to determine frequency, method, treatment, or setting for a preventive item or service if not specified in the guideline.
• HIV prevention measures:
  • HIV testing: Required coverage for HIV screening for individuals aged 15 or older up to 64, and for individuals at increased risk per CDC guidance.
  • PrEP and PEP: Coverage for all preexposure prophylaxis (PrEP) and postexposure prophylaxis (PEP) related to HIV prevention or treatment.
  • Prior authorization/step therapy: Generally not required for PrEP/PEP, but if FDA has approved multiple therapeutic equivalents of a drug or product for HIV prevention, a plan is not required to cover all equivalents without prior authorization or step therapy if at least one therapeutically equivalent version is covered without it.
• Grandfathered plans and certain associations: The new requirements do not apply to grandfathered plans or to plans offered by the Minnesota Comprehensive Health Association.

Significant changes to existing law

• Broadens the scope of items and services that must be covered without cost-sharing, tying them to widely used national guidelines (USPSTF, ACIP, AAP, HRSA guidance).
• Explicitly includes contraception methods and HIV prevention measures (HIV testing, PrEP, PEP) under no-cost-sharing requirements.
• Introduces an annual review mechanism to keep the covered preventive items list up to date.
• Establishes protections around in-network delivery and medical management, while allowing flexibility for out-of-network items.
• Limits applicability to non-grandfathered plans and excludes certain types of plans (e.g., Minnesota Comprehensive Health Association) from these requirements.

Implementation and administration

• Health plan companies must implement no-cost-sharing coverage for participating providers.
• Plans may use medical management strategies to manage frequency/methods where guidelines do not specify.
• The annual review requirement ensures the list of covered items can evolve with new guidance.
• Exceptions apply for out-of-network services, grandfathered plans, and certain plan types.

Relevant terms section follows.

Relevant Terms - preventive items and services - cost-sharing - deductible - coinsurance - copayment - health plan company - participating provider - out-of-network - immunizations / vaccines - routine use - United States Preventive Services Task Force (USPSTF) - A or B rating - Advisory Committee on Immunization Practices (ACIP) - Centers for Disease Control and Prevention (CDC) - American Academy of Pediatrics (AAP) - West Coast Health Alliance - Health Resources and Services Administration (HRSA) - women’s preventive care guidelines - contraception methods - Food and Drug Administration (FDA) - preexposure prophylaxis (PrEP) - postexposure prophylaxis (PEP) - HIV testing / HIV screening - annual determination - medical management - grandfathered plans - Minnesota Comprehensive Health Association (MCHA)