Preventive care requirements: The ins and outs

Last week the departments of Health and Human Services, Treasury and Labor issued interim final rules explaining the preventive care requirements that non-grandfathered group health plans and individual insurers will have to provide for the first plan year beginning after Sept., 2010 (i.e., Jan. 1, 2011, for calendar-year plans)--with limited to no cost-sharing for plan members. The new rules represent "a more middle-of-the-road approach to Affordable Care Act implementation," noted Mark Stember with Kilpatrick Stockton LLP in a review for the Washington, D.C.-based Employers Council on Flexible Compensation (ECFC).

The basic preventive services involved include general preventive care, immunizations, preventive care for children and preventive care for women. Those general preventive services comprise "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," said Stember. The federal government's reliance on the volunteer Task Force opens up the organization to significant lobbying efforts from special interest groups that want to get their pet issue an A or B rating, report the Kaiser Health News and the Washington Post.

Under the rules, health plans won't be able to "impose any cost-sharing requirements on the items and services considered to be preventive care--meaning 100 percent coverage with no deductibles, co-payments or co-insurance," said Stember. However, those restrictions come with some important caveats. First, it matters how the preventive services are billed. "For example, if the preventive service is billed separately (e.g., a cholesterol screening), then the plan can impose cost-sharing requirements with respect to the related office visit. However, if the preventive service is not billed separately from an office visit (e.g., required weight management counseling) and the primary purpose of the office visit is the delivery of the preventive care service, then the plan may not impose any cost-sharing requirements with respect to that office visit," he pointed out.

In addition, the preventive care cost-sharing rules apply only to network providers. "This means that coverage for the preventive care items and services ... is not required if the item or service is provided out-of-network," said Stember. "Further, if a plan did cover some of the preventive care items or services out-of-network, it could subject those items and services to the plan's deductible and apply co-insurance requirements." The rules also allow health plans some latitude with regard to using medical management to set coverage limitations and providing preventive care such as drug regimens that result from the specified preventive services, he added.

To learn more:
- read this Kaiser Health News/Washington Post article
- read this ECFC review
- read this Health Affairs blog post
- access the rule here

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