Preventive Care Coverage

Section 2713 of the Public Health Service Act (the “Act”), as added by the Patient Protection and Affordable Care Act (“PPACA”), requires group health plans and health insurance issuers that are not grandfathered health plans to provide a wide array of preventive care items and services with no cost-sharing.

This means that no deductibles, copays, coinsurance, or other cost-sharing measures otherwise imposed on plan participants can be imposed for specified in-network preventive care services.

On July 14, 2010, the Departments of Health and Human Services, Labor, and Treasury (the “Departments”) jointly published a new Interim Final Rule relating to coverage of preventive health services under PPACA.  The Interim Final Rule was effective September 17, 2010, and impacted non-grandfathered group health plans and health insurance issuers beginning on the first plan or policy year beginning after September 23, 2010.

Women’s Preventive

On August 1, 2011, the Health Resources and Services Administration (“HRSA”) issued new Guidelines for Women’s Preventive Services that must be covered without cost sharing in new and non-grandfathered health plans effective August 1, 2012 (January 1, 2013 for calendar year plans) pursuant to the PPACA preventive care mandate. The guidelines were recommended after completion of a commissioned study by the Institute of Medicine (IOM).

Based on HRSA’s updated guidelines, additional women’s preventive services that must be covered by non-grandfathered health plans and health insurance issuers (including issuers in the individual market) without imposing cost sharing requirements include:

• Well-woman visits: This includes at least one annual well-woman preventive care visit for adult women to obtain the recommended preventive services; coverage for additional visits is required if providers determine that additional visits are necessary due to a women’s health status, health needs and other risk factors.
• Gestational diabetes screening: This screening is for women 24 to 28 weeks pregnant, and on the first prenatal visit for women identified as being at high risk of developing gestational diabetes.
• HPV DNA testing: Women who are 30 or older must have access to high-risk human papillomavirus (HPV) DNA testing every three years, regardless of pap smear results.
• STI counseling: Sexually-active women must have access to annual counseling on sexually transmitted infections (STIs).
• HIV screening and counseling:  Sexually-active women must have access to annual screening and counseling for human immune-deficiency virus infections (“HIV”).
• Contraception and contraceptive counseling:  Except for a narrow exception for health plans sponsored by religious employers, women must have access to all FDA-approved contraceptive methods, sterilization procedures, and patient education and counseling. These recommendations do not include abortifacient drugs (such as the so-called “morning-after pill”).
• Breastfeeding support, supplies, and counseling: Pregnant and postpartum women must have access to comprehensive lactation support and counseling from trained providers, and plans must cover costs for renting breastfeeding equipment.
• Domestic violence screening: Access to screening and counseling for interpersonal and domestic violence must be provided annually for all women.

Examples

In-Network Examples as provided in Interim Final Rule.

Example 1

Facts
An individual covered by a group health plan visits an in-network health care provider. While visiting the provider, the individual is screened for cholesterol abnormalities, which has in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force with respect to the individual. The provider bills the plan for an office visit and for the laboratory work of the cholesterol screening test.

Conclusion
In this Example 1, the plan may not impose any cost-sharing requirements with respect to the separately billed laboratory work of the cholesterol screening test. Because the office visit is billed separately from the cholesterol screening test, the plan may impose cost-sharing requirements for the office visit.

Example 2

Facts
Same facts as Example 1. As the result of the screening, the individual is diagnosed with hyperlipidemia and is prescribed a course of treatment that is not included in the recommendations under the regulations.

Conclusion
In this Example 2, because the treatment is not included in the recommendations under the regulations, the plan is not prohibited from imposing cost-sharing requirements with respect to the treatment.

Example 3

Facts
An individual covered by a group health plan visits an in-network health care provider to discuss recurring abdominal pain. During the visit, the individual has a blood pressure screening, which has in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force with respect to the individual. The provider bills the plan for an office visit.

Conclusion
In this Example 3, the blood pressure screening is provided as part of an office visit for which the primary purpose was not to deliver items or services described in the regulations.  Therefore, the plan may impose a cost-sharing requirement for the office visit charge.

Example 4

Facts
A child covered by a group health plan visits an in-network pediatrician to receive an annual physical exam described as part of the comprehensive guidelines supported by the Health Resources and Services Administration. During the office visit, the child receives additional items and services that are not described in the comprehensive guidelines supported by the Health Resources and Services Administration, nor otherwise described in the regulations. The provider bills the plan for an office visit.

Conclusion
In this Example 4, the service was not billed as a separate charge and was billed as part of an office visit. Moreover, the primary purpose for the visit was to deliver items and services described as part of the comprehensive guidelines supported by the Health Resources and Services Administration. Therefore, the plan may not impose a cost-sharing requirement with respect to the office visit.

Additional Resources

Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under the Patient Protection and Affordable Care Act

Complete List of USPSTF Grade A and B Recommendations

Recommended Immunization Schedule for Persons Aged 0 Through 6 Years

Recommended Immunization Schedule for Persons Aged 7 Through 18 Years

Catch-up Immunization Schedule for Persons Aged 4 Months Through 18 Years Who Start Late or Who Are More Than 1 Month Behind

Recommended Adult Immunization Schedule

Recommendations for Preventive Pediatric Health Care