"Preventive Services" – Interim Final Regulations Issued
July 20, 2010
On Wednesday, July 14, 2010, the Departments of Health and Human Services (HHS), Labor and the Treasury issued interim final regulations for compliance with the preventive services provision of the Affordable Care Act. The regulations apply to new health plans beginning on or after September 23, 2010, and require plans to cover preventive services that have strong scientific evidence of their health benefits. Under these "first dollar" rules, plans may not charge a copayment, coinsurance or deductible for these services when they are delivered by a network provider.
This provision does not apply to grandfathered plans.
U.S. Preventive Services Task Force Recommendations
Specifically, the recommendations include:
- Evidence-based preventive services: The U.S. Preventive Services Task Force, an independent panel of scientific experts, rates preventive services based on the strength of scientific evidence documenting their benefits. Preventive services with a "grade" of A or B – like breast and colon cancer screenings; screening for vitamin deficiencies during pregnancy; screenings for diabetes, high cholesterol and high blood pressure; and tobacco cessation counseling – are covered under these rules.
- Routine vaccines: Health plans will cover a set of standard vaccines recommended by the Advisory Committee on Immunization Practices ranging from routine childhood immunizations to periodic tetanus shots for adults.
- Prevention for children: Health plans will cover preventive care for children, following recommendations of the Bright Futures guidelines developed by the Health Resources and Services Administration together with the American Academy of Pediatrics. These guidelines provide pediatricians and other health care professionals with recommendations for the services they should provide to children from birth to age 21 to keep them healthy and improve their chances of becoming healthy adults. The types of services that will be covered include: regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations and screening, and counseling to address obesity and help children maintain a healthy weight.
- Prevention for women: Health plans will cover preventive care provided to women under both the Task Force recommendations and new guidelines being developed by an independent group of experts – including doctors, nurses and scientists – which are expected to be issued by August 1, 2011.
- A complete list of recommended preventive services can be found here.
Cost-sharing may still be imposed on preventive services not covered in the Task Force recommendations, such as:
- Preventive Services Not Recommended: Plans may still impose cost-sharing for those preventive services not covered in the recommendations.
- Out-of-Network Preventive Services: Plans may impose cost-sharing for preventive services included in the recommendations if those services are provided out-of-network.
- Frequency, Method, Treatment or Setting Limitations: Many of the covered preventive services include a recommendation as to frequency, method, treatment or setting for a particular service. A plan may limit coverage of preventive services to correspond to such recommendation. To the extent the recommendation does not include a recommendation relating to frequency, method, treatment or setting, however, the interim final rules allow the plan to use "reasonable medical management techniques" to determine coverage limitations.
- Treatment for Conditions Diagnosed through Preventive Services: Plans may impose cost-sharing for the treatment of conditions diagnosed as a result of one of the recommended preventive services.
Resources
Use the following links to access important resources and information about the preventive services provision:
Recommended preventive services
This communication is intended as an overview and should not be viewed or relied upon as legal or tax advice. Please consult your attorney or tax professional if you have any questions about this legislation.
