HRB 10 - Preventive Health Services
Released July 15, 2010I Download as a PDF July 15, 2010
-- On July 14, 2010, the Departments of HHS, Labor, and Treasury issued interim final regulations
relating to the preventive care provisions of the health reform law (PPACA). These rules require health plans to cover certain preventive services, without imposing any cost-sharing requirements (co-pay, co-insurance, or deductible), when such services are delivered by in-network providers.
These regulations apply to plans on the first day of the first plan year beginning on or after September 23, 2010. The rules apply to non-grandfathered plans, and plans that lose grandfathered status.
Types of Covered Preventive Services
Of particular note, the regulations include a list of the kinds of preventive services that must be provided. The list includes specific covered preventive services for adults, women, including pregnant women, and children, and will be updated periodically. Preventive services include those recommended by:
- The U. S. Preventive Services Task Force;
- The Advisory Committee on Immunization Practices adopted by the Director of the Centers for Disease Control and Prevention; and
- Comprehensive Guidelines Supported by the Health Resources and Services Administration:
- Periodicity Schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care; and
- Uniform Panel of the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children.
Services Provided Out-of-Network. The regulations clarify that preventive services provided by an out-of-network provider can be subject to cost-sharing. The regulations also address the preventive care rules as they relate to office visits. In a nutshell, if the preventative service and office visit are charged separately, a cost share can be imposed on the office visit, if appropriate; but not on the preventive service.
Conversely, if the office visit and preventive services are charged together, whether a cost share can be imposed depends on the primary purpose of the office visit. If the primary purpose of the office visit is preventive services, no cost share can be imposed.
Also note a plan may require coverage of preventive services not included in the list of preventive services. As always, the terms of the plan govern, as long as they are compliant with the law.
The information contained herein is not intended to be legal, accounting, or other professional advice, nor are these comments directed to specific situations. The information contained herein is provided as general guidance and may be affected by changes in law or regulation. This information is not intended to replace or substitute for accounting or other professional advice. You must consult your own attorney or tax advisor for assistance in specific situations.
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