Highlight on New York: State guidance supports ACA initiatives

The New York Department of Financial Services (NYDFS) recently released guidance to ensure that insurers are following through on Patient Protection and Affordable Care Act (ACA) (P.L. 111-148) and CMS mandates to provide preventive services recommended by the U.S. Preventive Services Task Force (USPSTF) at no charge to patients and to facilitate enrollment during special enrollment periods (SEPs). Specifically, it circulated guidance requiring issuers to provide coverage for maternal depression screening and to allow victims of domestic violence to apply for health insurance coverage, both on and off the exchange, year-round.

Maternal Depression Screening

Section 1001 of the ACA amended section 2713 of the Public Health Service Act (42 U.S.C. § 300gg-13) to require nongrandfathered health plans to provide certain preventive services, without copays, to plan recipients. The services fall into four categories, one of which covers evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the USPSTF.  In 2009, the USPSTF recommended screening all adults for depression when staff-assisted depression care supports were in place and suggested selective screening based on professional judgment and patient preferences when such supports were not in place.  Since that time, depression care supports have become more commonplace.  As a result, the task force updated its recommendations in 2016 to omit the recommendation regarding selective screening and recommend depression screening for all adults, specifically including pregnant and postpartum women; the rating carries with it a ‘B’ recommendation. The USPSTF noted that the American Academy of Pediatrics recommends postpartum depression screening at infants’ one-, two-, and four-month visits, while the American College of Obstetricians and Gynecologists recommends screening at least once during the perinatal period.

The NYDFS issued guidance to insurers on April 25, 2016, reminding them that the USPSTF granted maternal depression screening a ‘B’ rating and that they are required to covers such services pursuant to 42 U.S.C. § 300gg-13. According to Governor Cuomo’s office, issuers should begin providing coverage as soon as possible, but no later than six months from the date of the notice. Furthermore, the NYDFS noted, Chapter 199 of the Laws of 2014 (which added §§ 3217-g, 4306-f, and 4406-f), requires that insured women are entitled to direct access to screening and referral  for maternal depression treatment by an obstetrician/gynecologist (OB/GYN) or pediatrician of their choice. In addition, existing law requires that mental health services have parity in insurance coverage.

SEPs for Victims of Domestic Violence

Qualified individuals or enrollees and their dependents are eligible for special enrollment periods, pursuant to 45 C.F.R. 155.420(d)(9), if they meet specified exceptional circumstances. As of July 27, 2015, CMS opened a permanent SEP for any household members victim to domestic abuse, victims of spousal abandonment, and their dependents, for 60 days following an individual’s request for enrollment. CMS also noted that victims who are married to their abuser or abandoner and are applying for coverage separately may be eligible for advance premium tax credits (APTCs) and cost-sharing reductions (CSRs); the federally-facilitated marketplace will  allow them to indicate that they are unmarried without fear of penalty, but other marketplaces may also elect to attest to an expected filing status of Married Filing Separately.

The NYDFS notified all insurers and health maintenance organizations (HMOs) offering comprehensive health insurance coverage in the individual market that they should honor this SEP, whether they offer coverage on or off New York State of Health (NYSOH), the state exchange. The governor’s announcement noted that the SEP began April 15, 2016. Coverage for applications received through the 15th of any month will go into effect on the first day of the following month, while applications received after the 15th will be effective the first day of the second following month.  Although insurers and HMOs may request a separate statement or include an item on the application regarding eligibility, they may not require proof of eligibility or other overly burdensome requirements, nor may they require that applicants have been a victim of domestic violence or spousal abandonment with a specific timeframe.