Federal Agencies Issue Health Plan Rules for Preventive Services

stethoscope and apple.jpgUnder new rules issued Wednesday, non-grandfathered group health plans and health insurance issuers offering group or individual health insurance coverage on or after September 23, 2010 must provide a range of preventive services and eliminate any cost-sharing requirements, such as co-payments, coinsurance, or deductibles, for such benefits when they are offered by a network provider. Plans may still impose cost-sharing arrangements for services provided out-of-network. In addition, those plans that are considered “grandfathered” are exempt from these coverage requirements.

In essence, the rules mandate that non-grandfathered plans cover preventive services that have strong scientific evidence of their health benefits, as rated by the U.S. Preventive Services Task Force, an independent panel of scientific experts. Such services include breast and colon cancer screenings, screening for vitamin deficiencies during pregnancy, screenings for diabetes, high cholesterol and high blood pressure, and tobacco cessation counseling. Health plans subject to the new regulations also will be required to cover a set of standard vaccines recommended by the Advisory Committee on Immunization Practices for both children and adults.

The rules also require coverage for preventive care for women and children. The recommended services for children will be developed by the Health Resources and Services Administration with the American Academy of Pediatrics, and include services for children up to age 21 such as regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity.

With respect to preventive care for women, recommendations and guidelines developed by the Task Force and other medical care experts are expected to be issued by August 1, 2011. More details on the types of covered preventive services can be found here. The Department of Health and Human Services (HHS) also has provided a webpage for insurance providers and medical professionals that lists and explains all recommended preventive services covered by the regulations. The information provided on that page will be updated as new recommendations and guidelines are formulated.

Plans are to provide such preventive coverage for plan years beginning on or after September 23, 2010, or one year from the date the recommendation or guideline announcing the covered protective service is issued.

The rules also clarify cost-sharing arrangements when a recommended preventive service (RPS) is provided during an office visit.

  • If the RPS is billed separately from an office visit, the healthcare provider may require cost-sharing for the office visit.  For example, if a cholesterol test is provided during a routine office visit, the provider may require a co-pay for the office visit.
  • If the RPS is the primary purpose of the office visit and is not billed separately, then co-pays or other cost-sharing measures may not be imposed.
  • If the RPS is not the primary purpose of the visit, and the charge is not billed separately from the office visit, the regular cost-sharing arrangement may still be imposed for the office visit.
  • Treatment resulting from a RPS can be subject to cost-sharing requirements if the treatment itself is not considered a RPS.
  • A plan also has the option of covering preventive services other than those mandated by the rules – including those that have ceased to be considered a RPS – and may impose cost-sharing requirements on those additional services.

It is estimated that these rules will increase non-grandfathered group health plan premiums by approximately 1.5%.

This entry was written by Ilyse Schuman.

Photo credit: ODonnell Photograf

Information contained in this publication is intended for informational purposes only and does not constitute legal advice or opinion, nor is it a substitute for the professional judgment of an attorney.