Tuesday, July 20, 2010

Interim final regulation released on preventive care coverage requirement

The Departments of Health and Human Services, Labor and Treasury released an interim final regulation on July 14th, which expands on the requirement for health plans to cover preventive care with no cost-sharing as set forth in the Patient Protection and Affordable Care Act (PPACA).

PPACA requires that all plans provide first-dollar coverage of specific preventive services beginning on the first day of the first plan year following September 23, 2010. This requirement applies to all individual and group health plans, including self-funded plans, with the exception of grandfathered plans as long as they retain their grandfathered status.

Preventive services that must be covered at 100% include:
• Recommendations of the United States Preventive Services Task Force (USPSTF) with a grade A or B (click to access the Complete List of USPSTF Grade A/B Recommendations)
• Recommendations of the Advisory Committee on Immunization Practices (ACIP) as adopted by the Director of the Centers for Disease Control and Preventive (CDC)
• Guidelines supported by the Health Resources and Services Administration (HRSA)

For links to the above recommendations, click to access Recommended Preventive Services Summary on Healthcare.gov.

Not only do the rules outline which preventive services must be covered without cost-sharing, they also specify how cost-sharing will work under specific scenarios. For example:
• If a recommended preventive service is billed separately from an office visit, then cost-sharing may be applied to the office visit.
• If a recommended preventive service is not billed separately from an office visit and the primary purpose of the office visit is the delivery of such service, then cost-sharing requirements may not be imposed with respect to the office visit.
• If a preventive care screening or service results in a need for additional care or medication, cost-sharing can apply to the patient’s treatment.
• Out-of-network cost-sharing rules will apply to any recommended preventive services received from an out-of-network provider.
• If the federal recommendations do not specify the frequency, method, treatment or setting for the provision of a particular preventive service, the plan can determine reasonable coverage limitations.
• If a plan covers preventive services above and beyond the new federal requirements, the plan can impose cost-sharing requirements on those services.

Additionally, if a federal preventive care service recommendation changes, the plan is no longer required to provide first-dollar coverage on that service. For more information, click to access the Interim Final Preventive Regulations.

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