Can a high-deductible health plan (HDHP) that is qualified to pair with a health savings account (HSA) cover breast MRIs or ultrasounds as preventive care (e.g., with no cost sharing or cost sharing that occurs before the HDHP minimum annual deductible is met) without putting participants’ ability to contribute to the HSA at risk?
An HDHP can likely cover breast MRIs or ultrasounds with or without deductibles, coinsurance or copayments prior to the HDHP minimum annual deductible being met because breast cancer screening is listed as a safe harbor by the IRS (see Notice 2004-23). The safe harbor states that preventive care includes cancer screenings, specifically listing “Breast Cancer (e.g., Mammogram)” — which leaves open what other cancer screenings besides mammograms are included. So because the IRS guidance does not specifically address breast MRIs/ultrasounds, health plans should discuss this issue with legal counsel.
Under Internal Revenue Code section 223, to be eligible to contribute to an HSA, an individual must be covered by an HDHP and have no disqualifying health coverage. To qualify as an HDHP, a group health plan may not pay for or reimburse healthcare expenses before the minimum annual deductible is met — with the exception of preventive care. An HDHP must have written rules on what coverage is considered “preventive” and available without a deductible (or with a deductible below the applicable minimum deductible, either self-only or family).
The IRS is the government agency tasked with defining “preventive care” under existing laws. Note: While other services (and drugs) may be preventive in nature (and even included on drug formularies), only those encompassed in IRS guidance can be covered prior to the deductible being met for an HDHP to remain HSA-qualifying.
Preventive care does not generally include any service or benefit intended to treat an existing illness, injury or condition. Under the HDHP/HSA rules, a benefit must be described as preventive care either for purposes of section 1861 of the Social Security Act or in guidance issued by the IRS.
The IRS has issued various notices regarding what is considered preventive care for HDHP/HSA purposes, including (1) a “safe harbor” definition, (2) the addition of coverage for treatment “incidental” to other preventive care, (3) the extension of the definition of preventive care to coordinate with the ACA’s preventive services mandate, and (4) the treatment of specific chronic conditions.
In a recent article published in HR Executive, “Why employers may need to reconsider breast cancer screening coverage," WTW’s Dr. Patricia Toro and Dr. Jeff Levin-Scherz note that employers are increasing their efforts to meet women’s health needs and promoting breast cancer screening. A result is that more employees are requesting that cost sharing be waived for breast ultrasounds or MRIs, which are clinically recommended for women who have dense breast tissue or a higher risk of cancer.
The U.S. Preventive Services Task Force (USPSTF) recently expanded its breast cancer recommendation for all women to start routine screening at age 40. However, younger women have denser breasts, and mammograms are less reliable to exclude breast cancer in this group. For these individuals, providers may be inclined to recommend an ultrasound or MRI as a second imaging test, after a mammogram.
