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July 22, 2019

IRS expands definition of preventive care for qualified high deductible health plans

Jennifer Stanley

In June, the Trump Administration issued Executive Order 13877 requiring various federal agencies to develop rules designed to assist patients in making informed decisions about their healthcare. A summary of this Executive Order can be found in our earlier Alert

In the Order, the IRS was directed to issue guidance permitting qualified high deductible health plans (HDHPs) to cover medical care for chronic conditions as preventive care.  This means the HDHP will be able to provide these benefits before the individual has met the applicable minimum annual statutory deductible without affecting a participant’s ability to make or receive health savings account contributions.  The IRS issued this guidance as IRS Notice 2019-45 on July 17, 2019.

The Bottom Line

  1. Expansion for Chronic Conditions – The existing definition for services that can be covered as preventive care under an HDHP has been expanded to include medical services and prescription drugs for certain chronic conditions.
  2. It’s a Choice – HDHPs are not required to cover these services as preventive care but may choose to do so.  We expect many HDHPs will be amended to adopt this expansion.


  3. Limited Services – The medical services and prescription drugs for certain chronic conditions that can be covered as preventive care are limited to a narrow list.
  4. For Certain Chronic Condition(s) – An individual must be diagnosed with the corresponding chronic condition, and the services must be prescribed to prevent the condition from worsening or to prevent the individual from developing another condition.

Note: Please see HDHP Preventive Care Safe Harbor below for more detail about eligible preventive care under an HDHP.

IRS Notice 2019-45 is effective as of July 17, 2019, and HDHPs may take advantage of it immediately.  It may be more practical for an HDHP to wait until the beginning of its next plan year to adopt the plan design change rather than adopting it mid-year. 

HDHP Preventive Care Safe Harbor
The Existing Rule
IRS guidance describes categories of services that may be covered as preventive care provided that the services or treatments are not for the treatment of an existing illness, injury, or condition.[1] The IRS has indicated the described categories are not intended to be exhaustive.

Existing Preventive Care Safe Harbor List (non-exhaustive)

Annual physicals, including necessary testing and diagnostic procedures

Routine prenatal care

Adult immunizations

Routine well-child care

Child immunizations

Obesity weight-loss programs

Cancer screening

Tobacco cessation programs

Infectious diseases screening

Heart and vascular diseases screening

Mental health conditions screening

Substance abuse screening

Metabolic, nutritional, and endocrine conditions screening

Osteoporosis screening

Obstetric and gynecologic conditions screening

Pediatric conditions screening

Vision disorders screening

Hearing disorders screening

Preventive services mandated by the Affordable Care Act (ACA)


As Expanded by IRS Notice 2019-45
The following services may now also be covered as preventive care.  This list is exhaustive.

Services for Specified Conditions

For Individuals Diagnosed with

Angiotensin Converting Enzyme (ACE) inhibitors

Congestive heart failure, diabetes, and/or coronary artery disease

Anti-resorptive therapy

Osteoporosis and/or osteopenia


Congestive heart failure and/or coronary artery disease

Blood pressure monitor


Inhaled corticosteroids


Insulin and other glucose lowering agents


Retinopathy screening


Peak flow meter




Hemoglobin A1c testing


International Normalized Ration (INR) testing

Liver disease and/or bleeding disorders

Low-density Lipoprotein (LDL) testing

Heart disease

Selective Serotonin Reuptake Inhibitors (SSRIs)



Heart disease and/or diabetes

Don’t Get Carried Away
IRS Notice 2013-57 added the ACA preventive services to the definition of preventive care for HDHPs in 2013.  IRS Notice 2019-45 does not affect the required preventive services that non-grandfathered medical plans must cover under the Affordable Care Act (ACA). 

The IRS earlier indicated in IRS Notice 2018-12 that male contraceptive services could not be covered as preventive care under an HDHP even when mandated by state law.[2]  IRS Notice 2019-45 does not change this earlier guidance.

[1] This guidance appears in several locations including Internal Revenue Code Section 223(c)(2)(C), IRS Notice 2004-23, IRS Notice 2004-50, Q/A #26 and 27, and IRS Notice 2013-57.

[2] IRS Notice 2018-12 provides for transition relief until January 1, 2020.

The information contained herein is for general informational purposes only and does not constitute legal or tax advice regarding any specific situation. Any statements made are based solely on our experience as consultants. Marsh & McLennan Agency LLC shall have no obligation to update this publication and shall have no liability to you or any other party arising out of this publication or any matter contained herein. The information provided in this alert is not intended to be, and shall not be construed to be, either the provision of legal advice or an offer to provide legal services, nor does it necessarily reflect the opinions of the agency, our lawyers or our clients. This is not legal advice. No client-lawyer relationship between you and our lawyers is or may be created by your use of this information. Rather, the content is intended as a general overview of the subject matter covered. This agency is not obligated to provide updates on the information presented herein. Those reading this alert are encouraged to seek direct counsel on legal questions. © 2019 Marsh & McLennan Agency LLC. All Rights Reserved.