On July 14, 2010, the Departments of Health and Human Services, Labor and Treasury released an interim final regulation outlining the details of the preventive care coverage requirement for health plans established by the Patient Protection and Affordable Care Act (PPACA).  

PPACA requires that all plans provide first-dollar coverage of specific preventive care services recommended by the United States Preventive Services Task Force beginning on the first day of the first plan year following September 23, 2010. The requirements apply to all individual and group health plans, including self-funded plans, but grandfathered plans are exempt as long as they retain their grandfathered status. The complete list of preventive care services that are required to be covered can be found here.

The new rules not only outline what screenings and preventive care services must be covered without being subject to cost-sharing, but they also establish how cost-sharing will work under a number of more complicated coverage scenarios. For example, when the preventive care is administered during an office visit, and that office visit would normally be subject to a deductible or co-payment, generally the preventive care will need to be billed separately for other cost-sharing to apply. Also, if a preventive care screening or service results in the patient needing additional care or medication, cost-sharing can apply to the patient’s treatment.

If the plan has a network, out-of-network cost-sharing rules will apply to any recommended preventive services a beneficiary receives from an out-of-network provider. And, if the federal recommendation or guideline for a preventive service does not specify the frequency, method, treatment or setting for the provision of that service, the plan or issuer can use reasonable medical management techniques to determine any coverage limitations. If a plan covers any preventive care services above and beyond the new federal requirements, then the plan can impose cost-sharing requirements on those services. 

Finally, the rules make it clear that if a federal preventive care service recommendation changes, the health plan is no longer required to provide first-dollar coverage of that particular service. Additional guidelines are being developed regarding preventive benefits and the utilization of value-based insurance designs by group health plans.

For more information on this or to get your free quote for health insurance, contact IBD Insurance today.

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