Coverage for Blood Lead Testing for One- and Two-Year Olds

The State of New Hampshire Insurance Department 21 South Fruit Street, Suite 14 Concord, NH 03301 David J. Bettencourt Commissioner Keith E. Nyhan Deputy Commissioner Telephone 603-271-2261 • Fax 603-271-1406 • TDD Access: Relay NH 1-800-735-2964 nh.gov/insurance Bulletin Docket No.: INS 24-001-AB TO: All Health Insurers FROM: Commissioner David J. Bettencourt DATE: January 11, 2024 RE: Coverage for Blood Lead Testing for One- and Two-Year Olds The New Hampshire Insurance Department has learned that, in certain instances, health insurers are assigning cost sharing for mandated blood lead testing for one and two-year olds.1 For all coverages subject to the Affordable Care Act (ACA), this practice is contrary to the ACA’s prohibition on cost sharing for preventive services, which includes lead screening for children at risk of exposure. ACA Requirements and Prohibitions The ACA requires “with respect to infants, children, and adolescents, evidenceinformed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration” (‘HRSA’) be provided without cost sharing.2 The HRSA follows the American Academy of Pediatrics’ (‘AAP’) guidelines, “Recommendations for Preventive Pediatric Health Care” (also known as “Bright Futures”). These guidelines include lead testing at intervals specified in the periodicity schedule found here: https://downloads.aap.org/AAP/PDF/periodicity_schedule.pdf. CMS also provides a list of all the preventive services for children not subject to cost sharing as per the AAP guidelines, which is found here: https://www.healthcare.gov/preventive-care-children/. Notably, “Lead screening for children at risk of exposure” is #22 on the list. AAP guidelines further elucidate “children at risk of exposure” as follows: “Pediatricians and other primary care providers should test asymptomatic children for elevated blood lead concentrations 1 See RSA 415:6-v and RSA 415:18-aa. 2 Public Health Service (PHS) Act section 2713, as added by the Affordable Care Act, and the interim final regulations at 75 FR 41726 (July 19, 2010). according to federal, local, and state requirements.”3 Therefore, the ACA prohibition of cost sharing for preventive services applies to children for whom blood lead testing is required, including children in New Hampshire for whom testing is universally mandated pursuant to RSA 130-A:5-a.4 Please also note that, according to recent CMS guidance, the ACA prohibition on cost sharing for preventive services extends not only to the initial testing, but also to follow-up testing when such testing “is an integral part of the preventive screening without which the screening would not be complete.”5 In the children’s blood lead screening context, this might occur when the initial test is a capillary test, which is inconclusive or which shows a positive result where guidelines recommend an immediate follow-up test by venous blood sample. Questions regarding this bulletin should be directed via email to Michelle Heaton at michelle.c.heaton@ins.nh.gov. 3 See #6 at https://www.aap.org/en/patient-care/lead-exposure/. 4 See RSA 130-A:5-a Universal Testing; Health Care Providers; Not Liable. – All health care providers who provide primary medical care shall conduct blood testing of all one and 2-year old patients to determine a blood lead level. A health care provider shall not be liable for not performing a test for blood lead level when a parent or guardian has been informed of the blood test requirement and has refused to consent or has failed to follow through in response to a referral for a test. Nothing in this section shall prevent a health care provider from recommending blood testing for children younger than one year or older than 2 years should circumstances, including potential lead hazard exposures, warrant such testing. (eff. Apr. 9, 2018) 5 See CMS guidance at https://www.cms.gov/cciio/resources/fact-sheets-and-faqs/downloads/faqspart-51.pdf, p.11.