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Plans Required to Cover Preventive Health Services

Among the many changes made by the Affordable Care Act (“ACA”) is a requirement that group health plans (other than plans that are “grandfathered” under the rules described in our June 2010 article) provide benefits for a comprehensive list of preventive health services.  Moreover, these benefits must be provided on a first-dollar basis (i.e., subject to no deductible or co-payment) and with no other cost-sharing requirement (such as coinsurance).  This requirement applies as of the first plan year beginning on or after September 23, 2010.

Mandated Preventive Services

In general, these mandated preventive services fall within the following three categories:

  • Evidence-based items or services carrying a current rating of either “A” or “B” in recommendations made by the U.S. Preventive Services Task Force;
  • Immunizations that are recommended for children, adolescents, or adults on the Immunization Schedules maintained by the Centers for Disease Control and Prevention; and
  • Evidence-informed preventive care and screenings for infants, children, adolescents, and women, as included in comprehensive guidelines issued by the Health Resources and Services Administration.

The complete and updated list of required preventive services is posted on the HealthCare.gov website.

Concurrent Office Visits

Because preventive care services are typically obtained during the course of an office visit, the regulations contain specific rules as to when a plan may impose cost-sharing requirements in connection with an office visit during which preventive care services are obtained.  For instance, if the office visit and preventive care services are billed separately, a plan may impose cost-sharing requirements with respect to the office visit.

The same rule applies if the office visit and preventive care services are not billed separately, but the “primary purpose” of the office visit was not to obtain preventive services.  However, if the items are not billed separately and the primary purpose of the visit was to obtain preventive care, a plan may not impose any cost-sharing requirements for either the visit or the preventive care.

Out-of-Network or Additional Preventive Care Services

In other respects, the regulations are surprisingly supportive of efforts by health plans to contain costs.  For instance, if a plan has a network of providers, it need not offer these preventive care services on an out-of-network basis. Alternatively, the plan may impose cost-sharing requirements on such services if obtained outside of its network.  The same is true for preventive care services that are covered under the plan, but that are not required to be provided pursuant to the Act.

Medical Management Techniques

Similarly, a plan is free to use “reasonable medical management techniques to determine the frequency, method, treatment, or setting” for required preventive care services.  The only limitation is that those techniques may not conflict with any of the recommendations contained in the applicable guidelines.

Effective Dates and Implementation

Although this new requirement applies to plan years beginning on or after September 23, 2010, the preventive care services required to be provided are those that were officially recommended at least one year before any plan year commences.  Accordingly, the first set of required services are those for which a recommendation was already in place by September 23, 2009.  The intent of this one-year lag is to allow plans time to add coverage for any newly recommended services.

Recommended Next Steps

Sponsors of plans that do not intend to retain their grandfathered status will want to review the list of recommended preventive care services and, as necessary, amend their plans to add coverage for any omitted services.  Moreover, any cost-sharing requirements applicable to these services will have to be eliminated.