Employers May Limit No-Cost Preventive Services to In-Network Care Under Interim Health Reform Regulations
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This week, the Departments of HHS, Labor and Treasury released interim final rules requiring group health plans and insurers to provide first-dollar coverage for certain recommended preventive items and services. The rules apply to non-grandfathered plans under the Patient Protection and Affordable Care Act (PPACA), providing additional clarity for companies that are in the process of weighing pros and cons of maintaining grandfathered status. The preventive services mandate takes effect for plan years beginning on or after September 23, 2010, or one year after an applicable recommendation or guideline is issued. In general, health plans must provide preventive benefits without cost-sharing for the following:
“evidence-based items or services” that have a rating of A or B in the current recommendations of the United States Preventive Services Task Force;
immunizations for routine use in children, adolescents, and adults that are recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;
“evidence informed” care and screenings for infants, children, and adolescents provided in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and
“evidence-informed” preventive care and screenings for women provided in comprehensive guidelines (to be issued by August 1, 2011) supported by HRSA (not otherwise addressed by the recommendations of the Task Force)..
Requirements Restricted to In-Network Coverage. A plan is not required to provide coverage for recommended preventive services delivered by an out-of-network provider if the plan utilizes provider networks. In addition, plans with provider networks may impose cost-sharing requirements for recommended preventive services delivered by an out-of-network provider.
Further Clarifications and Limitations on Requirements. The interim final regulations clarify when a plan may impose cost-sharing requirements for preventive services and provide examples:
If a recommended preventive service is billed separately or tracked separately from an office visit, then a plan or issuer may impose cost-sharing requirements with respect to the office visit.
If a recommended preventive service is not billed separately or tracked separately from an office visit and the primary purpose of the office visit is the delivery of such an item or service, then a plan or issuer may not impose cost-sharing requirements with respect to the office visit.
If a guideline for a recommended preventive service does not specify the frequency, method, treatment, or setting for the provision of that service, a health plan can use “reasonable medical management techniques” to determine any coverage limitations.
A plan may impose cost-sharing requirements at its discretion when it covers preventive services in addition to those required to be covered under PPACA.
A plan may impose cost-sharing requirements for a treatment that is not a recommended
preventive service, even if the treatment results from a recommended preventive service.
A plan is not required to provide coverage or waive cost-sharing requirements for any item or service that has ceased to be a recommended preventive service.
Agencies Seeking Guidance on Value-Based Plans. PPACA grants the agencies authority to provide guidelines for group health plans using value-based insurance designs as part of their offering of preventive health services. The interim final rules signal that the Administration is attempting to assist employers who use value-based plans to provide information and incentives for consumers to use higher value providers and treatments. The agencies are developing additional guidelines and seeking comments in this area.
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