2022-28661. Update to the Bright Futures Periodicity Schedule as Part of the HRSA-Supported Preventive Services Guidelines for Infants, Children, and Adolescents

AGENCY:

Health Resources and Services Administration (HRSA), Department of Health and Human Services.

ACTION:

Notice.

SUMMARY:

A Federal Register notice published on November 2, 2022, detailed and sought public comment on recommendations under development by the Bright Futures Pediatric Implementation Program (Bright Futures Program), regarding updates to the HRSA-supported preventive services guidelines for infants, children, and adolescents in the Bright Futures Periodicity Schedule. The proposed updates are specifically related to increasing the upper age limit for Human Immunodeficiency Virus (HIV) screening. The Bright Futures Program convenes health professionals to develop draft recommendations for HRSA's consideration. Ten comments were received and considered as detailed below. On December 30, 2022, HRSA accepted as final the Bright Future Program's recommended update to the HIV screening guideline. Under applicable law, non-grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage must include coverage, without cost sharing, for certain preventive services, including those provided for in the HRSA-supported preventive services guidelines for infants, children, and adolescents. The Departments of Labor, Health and Human Services, and the Treasury have previously issued regulations, which describe how group health plans and health insurance issuers apply the coverage requirements. Please see https://mchb.hrsa.gov/​programs-impact/​bright-futures for additional information.

FOR FURTHER INFORMATION CONTACT:

Bethany Miller, HRSA, Maternal and Child Health Bureau, telephone: [phone], email: [e-mail].

SUPPLEMENTARY INFORMATION:

Under the Patient Protection and Affordable Care Act, Public Law 111-148, the preventive care and screenings set forth in HRSA-supported guidelines are required to be covered without cost-sharing by certain group health plans and health insurance issuers. The Department adopted the Bright Futures Periodicity Schedule as a HRSA-supported guideline for infants, children, and adolescents under section 2713 of the Public Health Service Act. See 75 FR 41726, 41740 (July 19, 2010). To develop recommendations for HRSA's consideration, the Bright Futures Program convenes a panel of pediatric primary care experts to conduct rigorous reviews of current scientific evidence, solicit and consider public input, and make recommendations to HRSA regarding screenings and assessments recommended at each well-child visit from infancy through adolescence. HRSA then determines whether to support, in whole or in part, the recommended updates. The schedule of preventive care and screenings for infants, children, and adolescents is reflected in the Bright Futures Periodicity Schedule. This work is supported through the Bright Futures Program via cooperative agreement with the American Academy of Pediatrics.

The Bright Futures Program convenes a panel of pediatric primary care experts that examines the evidence to develop new (and update existing) recommendations for pediatric preventive services. The Bright Futures Program also disseminates final HRSA-supported recommendations through the annual publication of the updated Bright Futures Periodicity Schedule, with associated resources for practitioners and families.

The Bright Futures Program bases its recommended updates to the Guidelines on review and synthesis of existing clinical guidelines and new scientific evidence. Additionally, HRSA requires that the Bright Futures Program incorporate processes to assure opportunity for public comment in the development of the updated Bright Futures Periodicity Schedule.

The Bright Futures Program proposed and HRSA has accepted recommended updates to the Bright Futures Periodicity Schedule relating to increasing the upper age limit for Screening for HIV as detailed below.

Screening for HIV

In the current Bright Futures Periodicity Schedule, the age range recommended for adolescent universal screening for HIV is between the 15-year visit and 18-year visit. The Bright Futures Program proposed and HRSA has accepted an update that would expand the recommended age range for adolescent universal screening for HIV to between the 15-year visit and 21-year visit.

In the Bright Futures Periodicity Schedule, a “dot” with an “arrow” indicates a “range during which a service may be provided.” The previous guideline and updated guideline on HIV screening is reflected in the chart below:

All such screenings (universal and risk-based) within this age range are within the scope of the guideline. The update also includes an accompanying footnote to provide updated information about more frequent screening for youth assessed as at high risk of HIV infection. The full footnote reads: “Screen adolescents for HIV at least once between the ages of 15 and 21 making every effort to preserve confidentiality of the adolescent, as per “Human Immunodeficiency Virus (HIV) Infection: Screening” ( https://www.uspreventiveservicestaskforce.org/​uspstf/​recommendation/​human-immunodeficiency-virus-hiv-infection-screening), and after initial screening, youth at increased risk of HIV infection should be retested annually or more frequently, as per “Adolescents and Young Adults: The Pediatrician's Role in HIV Testing and Pre- and Postexposure HIV Prophylaxis” ( https://doi.org/​10.1542/​peds.2021-055207).

Discussion of Recommended Updated Guidelines

Early detection of an infection with HIV in adolescents and young adults can lead to improved health outcomes and reduce the further spread of HIV by individuals who are not yet aware they are infected. Universal screening is a type of screening that a provider may recommend without first identifying a specific risk factor or symptom. Given the sustained high numbers of people living with HIV in the United States; documented missed opportunities for HIV testing; advances in HIV diagnostics, treatment, and prevention; and age stratified epidemiological data around HIV incidence and HIV risk related behaviors, the range for universal screening is being extended to the 21-year visit.^[1 2] The aim is to better detect, treat, support, and prevent HIV infection among adolescents and youth, as well as the population at large.

A Federal Register notice on November 2, 2022 sought public comment on these proposed updates (87 FR 66197).^[3] The Bright Futures Program considered all public comments as part of its deliberative process and provided the comments to HRSA for its consideration. A total of 10 responders provided comments, the majority of whom agreed with the proposed update. Two respondents provided additional views. One comment suggested lowering the screening age range. Current clinical guidance to begin universal screening at age 15 is based on the age-stratified incidence of HIV infection and data on sexual activity in youth. No changes were made in response to this comment. The other comment did not specifically address HIV screening and is therefore beyond the scope of the proposed update.

After consideration of public comment, the Bright Futures Program submitted recommended updates for HIV screening to HRSA for consideration, as detailed above. On December 30, 2022, the HRSA Administrator accepted the Bright Futures Program recommendations and, as such, updated the guidelines. Non-grandfathered group health plans and health insurance issuers offering group or individual health insurance coverage must cover without cost-sharing the services and screenings listed as the HRSA-supported preventive services guidelines for infants, children, and adolescents for plan years (in the individual market, policy years) that begin one year after this date. Thus, for most plans, this update will take effect for purposes of the Section 2713 coverage requirement in 2024. Additional information regarding the Bright Futures Program can be accessed at the following link: https://mchb.hrsa.gov/​maternal-child-health-topics/​child-health/​bright-futures.html.

Authority: Section 2713(a)(4) of the Public Health Service Act, 42 U.S.C. 300gg-13(a)(4).

Carole Johnson,

Administrator.

Footnotes

1.  Hsu KKC, Rakhmanina NY, Chadwick EG. et al. Adolescents and young adults: the pediatrician's role in HIV testing and pre- and postexposure HIV prophylaxis. Pediatrics 2022; 149 (01) e2021055207.

2.  US Preventive Services Task Force Final Recommendation Statement: Human Immunodeficiency Virus (HIV) Infection: Screening. 2019. Available at: https://www.uspreventiveservicestaskforce.org/​uspstf/​recommendation/​human-immunodeficiency-virus-hiv-infection-screening.

3.   See https://www.federalregister.gov/​documents/​2022/​11/​02/​2022-23845/​notice-of-request-for-public-comment-on-proposed-update-to-the-bright-futures-periodicity-schedule.