HHS Releases Final Interim Guidance – Coverage of Preventive Health Services without Cost-Sharing

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.