Last week, the Departments of Labor, Treasury and Health and Human Services released yet another set of interim final regulations under the new Health Care Reform law. The regulations require non-grandfathered group health plans to provide coverage for certain in-network preventive services at no additional cost to the participant (i.e., no copayment, coinsurance, or similar cost-sharing). The rules are effective for plan years beginning on or after September 23, 2010, but do not apply to grandfathered plans.
The regulations require plans to cover preventive care items and services listed in the following four categories:
• Items and services rated “A” or “B” by the U.S. Preventive Services Task Force;
• Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;
• Preventive care and screenings for children recommended by the Health Resources and Services Administration; and
• Preventive care and screenings for women recommended by the Health Resources and Services Administration (this list is currently being developed and should be available by August 1, 2011).
The list of specific preventive care items and services currently recommended by these groups is available at http://www.healthcare.gov/center/regulations/prevention.html.
The regulations clarify that plans are permitted either to impose cost-sharing on out-of-network preventive care, or to exclude coverage for out-of-network preventive care altogether. Further, plans that provide preventive care services in addition to those required to be covered may impose cost-sharing on those additional services. Cost-sharing may also be imposed for treatment resulting from a preventive care item or service (e.g., treatment for high cholesterol detected through a preventive care cholesterol screening test).
The regulations also address rules for imposing cost-sharing where preventive services are accompanied by an office visit:
• If the preventive care item or service is billed or tracked separately from the office visit, the plan may impose cost-sharing for the office visit;
• If the preventive care item or service is not billed or tracked separately, but the primary purpose of the visit was something other than to receive the preventive care item or service, the plan may impose cost-sharing for the office visit;
• If the preventive care item or service is not billed or tracked separately, and the primary purpose of the visit was to receive the preventive care item or service, the plan may not impose cost-sharing for the office visit.
Finally, the regulations acknowledge that the list of required preventive care items and services will change periodically and that plans need time to implement the revisions. As a result, a plan is only required to provide coverage for a particular preventive care item or service for plan years beginning on or after the date that is one year from the date the item or service is added to the list of required preventive care items and services. For example, if a plan operates on a calendar year basis, the plan’s preventive care benefits as of January 1, 2012 must reflect items and services on the list as of January 1, 2011. Additionally, a plan may discontinue coverage for a preventive care item or service that is dropped from the list, but generally must provide participants with 60-day advance notice of the change.
Any new group health plan established on or after March 23, 2010 will need to comply with the new preventive care regulations for plan years beginning on or after September 23, 2010. Further, any plan that is currently grandfathered should consider these preventive care rules in evaluating the potential overall impact of losing grandfathered plan status.
If you have questions regarding the new preventive care regulations or any other Health Care Reform issues, please contact any member of the employee benefits practice group.