Sep 15, 2010

Update on Health Care Reform: The Preventive Service Rules

The Department of the Treasury, Department of Labor and Department of Health and Human Services issued interim final rules addressing a key aspect of the health care reform legislation affecting non-grandfathered health plans – the preventive service coverage requirements.

The preventive service coverage rules (the “Preventive Service Rules”) generally require that group health plans and insurers cover certain types of preventive services without imposing any cost-sharing requirements. These rules are effective for plans years beginning on or after September 23, 2010 – January 1, 2011 for calendar year plans.

Recommended Preventive Services

The Preventive Service Rules require group health plans and insurers to cover certain in-network preventive care services and items (referred to as “recommended preventive services”) without the imposition of cost-sharing requirements (e.g., co-payments, coinsurance, or deductibles). Generally, the Preventive Service Rules apply to:

  • Evidence-based items or services that have in effect a rating of A or B in the U.S. Preventive Services Task Force recommendations;
  • Immunizations for children, adolescents and adults as recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and
  • Evidence-informed preventive care and screenings for infants, children, adolescents and women
    in comprehensive guidelines supported by the Health Resources and Services Administration.

A complete list of the recommended preventive services can be accessed here.

The Preventive Service Rules provide that plans and insurers are not required to cover or waive cost-sharing for items or services that cease to be listed as “recommended preventive services.”

Cost-Sharing and Office Visits

The Preventive Service Rules contain the following specific requirements regarding cost-sharing requirements and office visits:

  • If a preventive service is billed separately from an office visit, the plan may impose cost-sharing requirements with respect to the office visit.
  • If a preventive service is not billed separately from an office visit, and the primary purpose of the office visit is delivery of the preventive service, the plan may not impose cost-sharing requirements with respect to the office visit.
  • If a preventive service is not billed separately from an office visit, and the primary purpose of the office visit is not the delivery of the preventive service, the plan may impose cost-sharing requirements with respect to the office visit.

Out-of-Network Services

The Preventive Service Rules clearly provide that plans and insurers are not required to cover out-of-network preventive services, and cost-sharing requirements may be applied to out-of-network preventive services.

For more information on the Preventive Service Rules and other aspects of the health care reform legislation, please contact your SGR Executive Compensation and Employee Benefits counsel.


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