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Preventative Care Regulations Released

One of the provisions of the recently passed national health reform law stipulates that for new plans, preventive care must be covered at a certain level of benefits. As is the case with most of the new reform provisions, the various regulations and guidance stipulating coverage and enactment requirements are being issued. Such is the case with the new preventive care benefit. Recently issued regulations require new private health plans to cover evidence-based preventive services and eliminate cost sharing requirements for such services. The rules generally apply to group health plans for plan years beginning on or after September 23, 2010, but do not apply to "grandfathered plans" (meaning certain plans in existence on the health reform law's March 30, 2010 enactment date).

Under the regulations, new health plans must cover preventive services that have strong scientific evidence of their health benefits (such as mammograms, colonoscopies and immunizations), and these plans may no longer charge a patient a copayment, coinsurance or deductible for these services when they are delivered by a network provider. The regulation links to a complete list of recommendations and guidelines that are required to be covered and refers to those items and services as "recommended preventive services." Specifically, these recommendations include:

  • Evidence-based preventive services, like breast and colon cancer screenings, screening for vitamin deficiencies during pregnancy, screenings for diabetes, high cholesterol and high blood pressure, and tobacco cessation counseling will be covered under these rules. 

  • Routine vaccines ranging from routine childhood immunizations to periodic tetanus shots for adults. 

  • Prevention for children from birth to age 21, including regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity and help children maintain a healthy weight. 

  • Prevention for women under both existing recommendations and new guidelines being developed by an independent group of experts which are expected to be issued by August 1, 2011.

The rules clarify that a plan is not required to provide coverage for recommended preventive services delivered by an out-of-network provider, and also clarify that a plan may impose cost-sharing requirements for recommended preventive services delivered by an out-of-network provider. According to the preamble of the regulations, the agencies are developing additional rules and are seeking comments related to the development of guidelines for group health plans to utilize value-based insurance designs that promote consumer choice of providers or services that offer the best value and quality, while ensuring access to critical, evidence-based preventive services.

As new information is issued on health reform, Conner Strong will issue alerts and updates. Should you have any questions, please contact your Conner Strong representative toll-free at 1-877-861-3220.

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