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Health Care Reform Update: Guidance Issued on Coverage of Preventive Services

July 16, 2010

The Department of Health and Human Services (HHS), the Internal Revenue Service, and the Department of Labor jointly issued interim final regulations requiring new (i.e., non-grandfathered) health plans to cover listed preventive services and eliminate cost-sharing requirements for such services under the Patient Protection and Affordable Care Act (PPACA). 

The regulations will apply to employers that offer non-grandfathered plans after September 23 (effective January 1, 2010, for calendar-year plans). Similar to previously released rules, grandfathered plans are exempt from the mandate to provide full first-dollar coverage for preventive services.

Services such as blood pressure, diabetes and cholesterol tests; many cancer screenings; routine vaccinations; and regular wellness visits for infants and children will become more accessible for many Americans under these rules. Currently, Americans use preventive services at about half the recommended rate, HHS estimates. Under the regulations, new health plans must cover these preventive services without charging patients a co-payment, co-insurance, or deductible for preventive services delivered by a network provider. However, institutions will be able to continue cost-sharing requirements for preventive services that employees receive from out-of-network providers. 

Covered Preventive Services

  • Pediatric care. New health plans must cover preventive care for children recommended under the Bright Futures guidelines, developed by the Health Resources and Services Administration with the American Academy of Pediatrics. These guidelines recommend the services that pediatricians and other health care professionals should provide to children up to age 21, including regular pediatric visits, vision and hearing screenings, developmental assessments, immunizations, and screening and counseling to address obesity and help children maintain a healthy weight.
  • Prevention for women. Health plans must cover preventive care for women as identified by the U.S. Preventive Services Task Force and detailed in the new regulations. Such care includes anemia and infection screening for pregnant women and breast cancer mammography screenings every one to two years for women over 40. In addition, an independent group of experts-including doctors, nurses, and scientists-has developed new guidelines on required preventive services; these are expected to be issued by Aug. 1, 2011.
  • Preventive services. The U.S. Preventive Services Task Force rates preventive services. Those receiving a grade of A or B are covered under these rules, including (with some limitations) breast and colon cancer screenings; screening for vitamin deficiencies during pregnancy; screenings for diabetes, high cholesterol, and high blood pressure; and tobacco cessation counseling. A list of covered preventive services for adults can be found at the government's healthcare.gov Web site.
  • Vaccines. New health plans will be required to cover a set of standard vaccines recommended by the Advisory Committee on Immunization Practices. These range from routine childhood immunizations to periodic tetanus shots for adults.

Next Steps

  • Sponsors of insured and self-insured group health plans should: 
  • Determine what changes to their existing preventive services are necessary to ensure compliance.
  • Determine cost/benefit of grandfathering with respect to preventive services.
  • Consult with their benefits adviser to ascertain the cost implications of compliance.
  • Coordinate with their carrier/TPA to ensure administrative compliance by the required effective date.
  • Update their summary plan description and other benefit materials to reflect any changes made to existing preventive services.    

Resources:

Preventive Regulations

Department of Health & Human Services Fact Sheet

Aon Consulting Health Care Alert

Contact

Tadu Yimam
Director, Distance Learning
202.861.2541
E-mail