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On July 14, the Departments of Treasury, Labor, and Health and Human Services jointly released Interim Final Rules (IFRs) for group health plans and health insurance issuers related to coverage of preventive services under the Patient Protection and Affordable Care Act (PPACA).
Under the regulations, plans must cover without copay, coinsurance or deductible – certain preventive services that have “strong scientific evidence of their health benefits.”
These are interim final rules (IFRs), which means final rules may eventually differ, but these rules are final in the interim. As additional clarification is made available whether through rule-making or otherwise, we’ll share that information with you.
General highlights of new regulations:
• Grandfathered plans are exempt for as long as they remain grandfathered.
• Non-grandfathered plans (i.e., plans either not in effect on March 23, 2010 or that made changes since then resulting in loss of grandfathered status) must comply with the no-cost-sharing requirement beginning with the first plan year on or after September 23, 2010.
• Preventive services are to be covered without any cost-sharing requirement when delivered by a network provider.
• Employers and insurers are not required to provide coverage for recommended preventive services delivered by an out-of-network provider or may impose cost-sharing for recommended preventive services delivered by an out-of-network health care provider.
• If a guideline for a recommended preventive service does not specify the frequency, method, treatment, or setting for the service, the plan or issuer may use "reasonable medical management techniques" to determine any coverage limitations on the service.
General list of services to be offered without copay, coinsurance or deductible:
Evidence-based preventive services: This list of items is taken from the current recommendations of the United States Preventive Services. They are included only if they have a rating of A or B. This broad list generally includes:
• Breast cancer and cervical cancer screenings
• Colon cancer screenings
• Screening for vitamin deficiencies during pregnancy
• Screenings for diabetes, high cholesterol and high blood pressure
Routine vaccinations: A list of immunizations – recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention – are included in the rule. They are considered routine for use with children, adolescents, and adults and range from childhood immunizations to periodic tetanus shots for adults.
Prevention for children: The rule includes preventive care guidelines for children – from birth to age 21 – developed by the Health Resources and Services Administration with the American Academy of Pediatrics. Services include regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity.
Prevention for women: The regulation mandates certain preventive care measures for women. These recommendations will be in place until new requirements for prevention for women are issued by the United States Preventive Services Task Force or appear in comprehensive guidelines supported by the Health Resources and Services Administration.
A full list of covered preventive services issued as part of the Interim Final Regulations may be reviewed at: http://www.healthcare.gov/center/regulations/prevention/taskforce.html
Billing and Office Visits.
If a recommended preventive item or service is billed separately from an office visit, then cost-sharing may be applied to the office visit.
If a recommended preventive item or service is not billed separately from an office visit and the primary purpose of the office visit is the delivery of such item or service, then cost-sharing requirements may not be imposed with respect to the office visit.
If a recommended preventive item or service is not billed separately from an office visit and the primary purpose of the office visit is not the delivery of the preventive item or service, then cost-sharing may be applied to the office visit.
Friday, July 16, 2010
GRANDFATHERING FACT SHEET
What is grandfathering?
Grandfathering allows groups and individual members that keep their existing plan from March 23, 2010, to January 1, 2014, to be exempt from the new product and rating framework that is effective in 2014. To maintain grandfathered status, a client must continue to keep the plan and the plan’s benefits essentially the same. Grandfathering also exempts plans from some of the requirements of the plan-related provisions effective September 23, 2010.
The following changes can be made without impacting grandfathered status:
• Changes in premiums of a policy or plan
• Changes required to comply with federal or state law
• Changes to increase benefits, or voluntarily comply with provisions of the Patient Protection and
Affordable Care Act
• Changes to plan structure, for example, switching from a health reimbursement arrangement to major
medical coverage, or from insured to self-funded coverage
• Changes to a provider network
• Changes to a prescription drug formulary
• Changes to accommodate mergers and acquisitions (as long as the merger or acquisition is not done solely
to allow a group to move from one grandfathered plan to another when the plan would reduce benefits or
increase cost sharing in excess of that allowed by the regulations)
• Changes to an ASO plan’s third party administrator
The following changes would cause a loss of grandfathered status:
• Eliminate all (or substantially all) benefits to diagnose or treat a particular condition.
• Increase coinsurance (or another percentage cost-sharing requirement) above the level at which it was set
on March 23, 2010. In other words, any increase in an insurer or plan’s coinsurance will result in a loss of
grandfathered status.
• Increase fixed-amount cost-sharing requirements other than copayments, such as a deductible or an out-
of-pocket limit, by a total percentage (measured from March 23, 2010) that is more than the sum of
medical inflation plus 15%.
• Increase copayments above the level in effect on March 23, 2010, by an amount that exceeds the grater of
(a) the sum of medical inflation plus 15%, or (b) $5 increased by medical inflation.
• Reduce employer contributions (calculated by cost or formula, such as hours worked) toward any tier of
group health insurance coverage or a group health plan by more than 5% below the contribution rate on
March 23, 2010.
• Impose an annual limit on the dollar value of benefits if an annual or lifetime limit had not been previously
imposed on all benefits or, for plans that previously imposed a life time limit of all benefits, imposed an
overall annual dollar limit that is lower than the lifetime limit, or for plans that previously imposed an annual
limit on all benefits, decreases the dollar value of the annual limit.
• Issuer or plan sponsor does not disclose to participants and beneficiaries that the plan or coverage is a
grandfathered health plan.
• Change from one insurer to another.
Grandfathering allows groups and individual members that keep their existing plan from March 23, 2010, to January 1, 2014, to be exempt from the new product and rating framework that is effective in 2014. To maintain grandfathered status, a client must continue to keep the plan and the plan’s benefits essentially the same. Grandfathering also exempts plans from some of the requirements of the plan-related provisions effective September 23, 2010.
The following changes can be made without impacting grandfathered status:
• Changes in premiums of a policy or plan
• Changes required to comply with federal or state law
• Changes to increase benefits, or voluntarily comply with provisions of the Patient Protection and
Affordable Care Act
• Changes to plan structure, for example, switching from a health reimbursement arrangement to major
medical coverage, or from insured to self-funded coverage
• Changes to a provider network
• Changes to a prescription drug formulary
• Changes to accommodate mergers and acquisitions (as long as the merger or acquisition is not done solely
to allow a group to move from one grandfathered plan to another when the plan would reduce benefits or
increase cost sharing in excess of that allowed by the regulations)
• Changes to an ASO plan’s third party administrator
The following changes would cause a loss of grandfathered status:
• Eliminate all (or substantially all) benefits to diagnose or treat a particular condition.
• Increase coinsurance (or another percentage cost-sharing requirement) above the level at which it was set
on March 23, 2010. In other words, any increase in an insurer or plan’s coinsurance will result in a loss of
grandfathered status.
• Increase fixed-amount cost-sharing requirements other than copayments, such as a deductible or an out-
of-pocket limit, by a total percentage (measured from March 23, 2010) that is more than the sum of
medical inflation plus 15%.
• Increase copayments above the level in effect on March 23, 2010, by an amount that exceeds the grater of
(a) the sum of medical inflation plus 15%, or (b) $5 increased by medical inflation.
• Reduce employer contributions (calculated by cost or formula, such as hours worked) toward any tier of
group health insurance coverage or a group health plan by more than 5% below the contribution rate on
March 23, 2010.
• Impose an annual limit on the dollar value of benefits if an annual or lifetime limit had not been previously
imposed on all benefits or, for plans that previously imposed a life time limit of all benefits, imposed an
overall annual dollar limit that is lower than the lifetime limit, or for plans that previously imposed an annual
limit on all benefits, decreases the dollar value of the annual limit.
• Issuer or plan sponsor does not disclose to participants and beneficiaries that the plan or coverage is a
grandfathered health plan.
• Change from one insurer to another.
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