Sarah Borders, CEBS September 4, 2024 4 min read

5th Circuit Court of Appeals Issues Decision on Coverage of ACA Preventative Services

On June 21, 2024, the U.S. Court of Appeals for the Fifth Circuit issued a ruling in the Braidwood Management Inc. v. Becerra case. While they agreed with the district court that the preventive care recommendations specifically made by the U.S. Preventive Services Task Force (USPSTF) are unconstitutional, they only chose to prohibit federal enforcement of the mandate against the case’s specific plaintiffs.

Who this applies to

Large employers with fully insured and self-funded health plans
Small employers with fully insured and level-funded health plans

Go Deeper:

In this ruling, the court agreed with the district court that the members of the USPSTF were unconstitutionally appointed and thus do not have the authority to determine the preventive services that must be covered by private health plans under the ACA’s preventive care mandate. This determination would mean that services recommended by the USPSTF would not be required to be covered at 100%. However, the court limited the application of their ruling to the plaintiffs in this case instead of applying an injunction nation-wide.

As a result, the government can still enforce the preventive care mandates recommended by the USPSTF against any insurer or plan that is not one of the insurers/plans represented in this lawsuit. Due to the precedence this decision sets, there’s also an argument that any other insurer/plan that falls under the jurisdiction of the Fifth Circuit could choose to challenge the constitutionality of the mandate.

The court also remanded the case back to the district court to determine if the recommendations of the Advisory Committee on Immunization Practices (ACIP) and Health Resources and Services Administration (HRSA) are also unconstitutional.

For much of the country, this decision reinstitutes the requirement to cover preventive services with an A or B rating from the USPSTF at 100%. It’s expected that the government and/or the plaintiffs will appeal to the Supreme Court of the United States to get a final answer on the constitutionality of the preventive mandate and its basis in the recommendations made by the USPSTF, ACIP, and HRSA.

While insurers and self-funded plan sponsors may have briefly been able to adjust their plans to get rid of cost-free preventive coverage, it seems that very few (if any at all) did so. We expect their posture to remain the same as this case continues to the Supreme Court.

Sarah Borders, CEBS

Principal, Benefits Compliance Solutions. Sarah has spent the last 15 years in the employee benefits industry, has numerous designations and serves on NAHU’s Employer Working Group Subcommittee and is an active board member of Austin AHU. She recently stepped down as Vice President of Benefits Compliance at one of the nation's largest brokerage firms to start her own compliance consulting practice. Her designations include an active license with the Texas Department of Insurance, CEBS (Certified Employee Benefits Specialist), Certified Health Care Reform Professional, HIPAA certification and Health Care Service Associate. She holds an MBA from Texas A&M Corpus Christi and a BA from University of Incarnate Word. Her consulting firm, Benefits Compliance Solutions, partners with employers to identify unknown risks and avoid hundreds of thousands of dollars in fines and lawsuits from failure to comply with their healthplan obligations.