Health insurers and group health plans will have to eliminate patient out-of-pocket costs for some types of preventive care services, but they may be able to use their usual rules for paying for the preventive-care office visits.
The Internal Revenue Service, the Employee Benefits Security Administration and the Office of Consumer Information and Oversight – a new arm of the U.S. Department of Health and Human Services — have announced the new rules for preventive services coverage in a batch of interim final regulations.
The regulations, which are set to appear in the Federal Register July 19, will implement a provision in the Affordable Care Act – the legislative package that includes the Patient Protection and Affordable Care Act (PPACA) – that added Section 2713 to the federal Public Health Service (PHS) Act.
PHS Section 2713 will require all group health plans that are not “grandfathered in,” and all suppliers of individual health insurance that are not grandfathered in, to provide preventive services benefits free of cost-sharing requirements.
Group or individual health insurance arrangements purchased or changed significantly after March 23, 2010, must provide benefits for:
- Preventive services that receive top marks from the U.S. Preventive Services Task Force.
- Immunizations recommended by the U.S. Centers for Disease Control and Prevention immunization practices advisory council.
- The preventive care and screenings recommended for babies, children and adolescents by the federal Health Resources Services Administration (HRSA).
- The preventive care and screening recommended for women that will be described in guidelines to be developed by Aug. 1, 2011.
The new preventive services benefits mandate will apply to group plan years started on or after Sept. 23, 2010, and for individual policy years starting on or after that date, officials say.
The U.S. Preventive Services Task Force can put a service on the preventive services list by giving it a grade of A or B. The task force now assigns grades of A to services such as cholesterol screenings for men over 35 and women over 45, screenings for high blood pressure in adults ages 18 and older, and screenings for colorectal cancer in adults ages 50 to 75.
Services that receive B grades from the task force include routine cholesterol screenings for young adults, screening for diabetes in adults without symptoms who have high or moderately high blood pressure, and mammography for women ages 40 and older every 1 or 2 years.
If a preventive service “is billed separately (or is tracked as individual encounter data separately) from an office visit, then a plan or issuer may impose cost-sharing requirements with respect to the office visit,” according to the text of the regulation.
If an individual goes to a doctor for a preventive service, such as a blood pressure check, and also gets some other kind of treatment, such as care for an earache, the plan can apply the usual cost-sharing rules to the care for the earache.
If a routine screening included in the mandate reveals health problems, the plan can apply its usual cost-sharing rules to efforts to treat the health problems.
“Nothing in this section requires a plan or issuer that has a network of providers to provide benefits for [preventive services] that are delivered by an out-of-network provider,” according to the regulation text.
Members of the public will have 60 days after the regulations are officially published in the Federal Register to submit comments.
The federal agencies involved decided to release the regulations as interim regulations, rather than completing a full public comment period first and developing a final rule, because of the rapidly approaching Sept. 23 compliance date imposed by Congress, officials say.