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Preventive Care Coverage under Health Care Reform

August 17, 2010

The health care reform law requires non-grandfathered health plans to cover specific preventive care services furnished by in-network providers with no cost-sharing starting with plan years that begin after September 23, 2010. Health plans are not required to provide coverage of preventive services furnished by out-of-network providers. Grandfathered plans are not required to comply with preventive services coverage requirements.

The preventive services coverage requirements apply to the following general categories of preventive services, referred to as “Recommended Preventive Services,” when furnished by an in-network provider:

·        Evidence-based services with a current “A” or “B” rating from the United States Preventive Services Task Force (the 2002 — and not the 2009 — recommendations regarding breast cancer screening, mammography and prevention are considered current). 

·        Immunizations recommended for routine use by the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention.

·        Child preventive care and screenings provided for in the guidelines supported by the Health Resources and Services Administration.

·        For women, the preventive care and screenings provided for guidelines under development by the U.S. Department of Health and Human Services.

You can find a complete and up-to-date list of Recommended Preventive Services at this website: http://www.healthcare.gov/center/regulations/prevention/recommendations.html. Please visit this website often; information may change as the government further defines its requirements for preventive care coverage.

Recognizing that the Recommended Preventive Services frequently may be furnished as part of office visits in which other health care services are provided, the federal agencies have adopted the following rules relating to cost-sharing requirements for such other services:

·        If a Recommended Preventive Service is billed separately from an office visit, a cost-sharing obligation may be imposed with respect to the office visit (but not the Recommended Preventive Service).

·        If (a) a Recommended Preventive Service is not billed separately from an office visit, and (b) the primary purpose of the office visit is the provision of the Recommended Preventive Service, a cost-sharing obligation may not be imposed for the office visit or the Recommended Preventive Service.

·        If (x) a Recommended Preventive Service is not billed separately from an office visit, and (y) the primary purpose of the office visit is not the provision of the Recommended Preventive Service, a cost-sharing obligation may be imposed for the office visit.