The United States Departments of Labor, Treasury and Health and Human Services jointly issued new regulations on July 14th outlining the scope of preventive and wellness services that health plans must offer without participant cost sharing, beginning on the first plan renewal following September 23, 2010. Although this requirement does not apply to “grandfathered” plans, early indications are that most plans are likely to lose “grandfather” status through the normal course of making renewal plan changes to address rising costs and benefit plan needs. Further, it is likely that these provisions will become “standard” benefits in most insurance carrier plans.
Note that preventive services are to be covered without any cost-sharing requirement when delivered by a network provider but plans are not required to provide coverage for recommended preventive services delivered by an out-of-network provider or may impose cost-sharing for recommended preventive services delivered by an out-of-network health care provider.
The following is a general list of services to be offered without co-pay, coinsurance or deductible:
- Evidence-based preventive services, generally including:
- Breast cancer and cervical cancer screenings
- Colon cancer screenings
- Screening for vitamin deficiencies during pregnancy
- Screenings for diabetes, high cholesterol and high blood pressure
- Routine vaccinations
- 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.
- Prevention for women
- Billing and Office Visits
- If a preventive item or service is billed separately from an office visit, cost-sharing may be applied to the office visit
- If a preventive item or service is not billed separately from an office visit and the primary purpose of the office visit is the delivery of such item or service, then cost-sharing requirements may not be imposed with respect to the office visit.
- If a preventive item or service is not billed separately from an office visit and the primary purpose of the office visit is not the delivery of that particular item or service, cost-sharing may be applied to the office visit.
The complete details can be found on the Department of Health and Human Services website by accessing the following link: HealthCare.Gov Preventive Services Announcement.