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Preventative Care Rules Released
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Definition of "Preventative Care." Under the interim rules, group health plans and health insurance issuers must cover and prohibit the imposition of cost-sharing requirements for the following categories of preventative care services:
(1) Evidence based items or services that have in effect a rating of A or B in the current recommendations of the US Preventative Services Task Force for the individual involved;
(2) Immunizations for routine use in children, adolescents, and adults as recommended by the CDC's Advisory Committee on Immunization Practices;
(3) For infants, children and adolescents, evidence-informed preventative care and screening provided for in the comprehensive guidelines supported by the Health Resources & Services Administration; and
(4) With respect to women, evidence-informed preventative care and screening provided for in comprehensive guidelines supported by HRSA. (To be issued no later than 8/1/2011).
The complete list of recommendations and guidelines is available at http://www.healthcare.gov/center/regulations/prevention.html
When Multiple Services Are Provided. The rules clarify how cost-sharing may or may not be applied when multiple services are provided. If a preventative care service is provided during an office visit but billed separately from the office visit, cost-sharing may be imposed on the office visit. If the preventative care service is not billed separately from an office visit and the primary purpose of the visit is not the preventative care service, cost-sharing may be applied to the office visit. If the preventative care service is not billed separately from an office visit and the primary purpose of the office visit is the preventative care service, cost-sharing is prohibited. The rules provide several examples of when cost sharing is and is not allowed. For example, if a patient receives a cholesterol screening test during a routine office visit, no cost sharing may be applied to the cholesterol screening but cost-sharing may be applied toward the office visit.
Out of Network Providers. A plan that distinguishes between in-network and out-of-network providers is not required to cover preventative care services provided by out-of-network providers and may impose cost-sharing on preventative care services provided by out-of-network providers.
Updates to Preventative Care Guidelines. Because preventative care recommendations change frequently, the Affordable Care Act provides that health plans and insurance issuers must have at least 1 year between when the recommendations or guidelines are issued and the plan year for which the services addressed in such recommendations or guidelines must be covered. The interim regulations provide that a recommendation or guideline must be covered at 100% starting with the first plan year beginning on or after the date that is one year after the new recommendation or guideline went into effect. For example, if a new recommendation is adopted on February 1, 2011, calendar year plans will have until January 1, 2013 to cover the new recommendation at 100%. For non-grandfathered plans who must start complying with the preventative care requirements with the first plan year on or after 9/23/10, the preventative care recommendations that will apply to them are those that were in effect as of 9/23/09.
The rules also clarify that if a recommendation or guideline is dropped, the health plan or issuer no longer has to cover the service at 100%. Health plans and issuers will need to check the applicable recommendations and guidelines once per year to determine whether any additional items or services must be covered without cost sharing and to determine whether any recommendations or guidelines have been dropped. The recommendations and guidelines can be found at http://www.healthcare.gov/center/regulations/prevention.html
For more information regarding the new rules, please contact your Davis Brown attorney or Susan Freed at (515) 288-2500.
