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Health Care Reform Guidance Issued on Required Coverage for Preventive Services

July 22, 2010

The Patient Protection and Affordable Care Act ("PPACA") requires non-grandfathered group health plans and health insurance issuers to cover and pay all costs of certain in-network preventive services without any deductibles, co-pays, or coinsurance charged to the participants. Interim final regulations were issued July 14, 2010, providing guidance on the preventive services that must be covered. These rules do not apply to grandfathered plans.

Group health plans and health insurance issuers must provide benefits for and prohibit cost sharing with respect to:

  • Evidence based items or services that have 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 involved.
  • Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved.
  • With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA).
  • With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA.

The complete list of recommendations and guidelines that are required to be covered can be found at http://www.health care.gov/center/regulations/prevention.html.

The preventive coverage must be provided for plan years (in the individual market, policy years) beginning on or after the later of September 23, 2010, or one year after the date the recommendation or guideline is issued. Thus, recommendations and guidelines issued prior to September 23, 2009 must be provided for plan years (in the individual market, policy years) beginning on or after September 23, 2010. Plans and issuers will have to make changes in coverage with respect to new recommendations and guidelines on the first day of the plan year (in the individual market, policy years) beginning on or after the date that is one year after the new recommendations or guidelines go into effect.

The interim final regulations clarify the cost-sharing requirements when a recommended preventive service is provided during an office visit. First, if a recommended preventive service is billed separately from an office visit, then a plan or issuer may impose cost-sharing requirements with respect to the office visit. Second, if a recommended preventive service is not billed separately from an office visit and the primary purpose of the office visit is the delivery of such an item or service, then a plan or issuer may not impose cost-sharing requirements with respect to the office visit. Finally, if a recommended preventive service is not billed separately from an office visit and the primary purpose of the office visit is not the delivery of such an item or service, then a plan or issuer may impose cost-sharing requirements with respect to the office visit.

With respect to a plan or health insurance coverage that has a network of providers, a plan or issuer is not required to provide coverage for preventive services delivered by an out-of-network provider; the plan or issuer may also impose cost-sharing requirements for preventive services delivered by an out-of-network provider.

Following is a current summary of preventive services that must be covered by plans and issuers, as published on the health care.gov website.

Covered Preventive Services for Adults

  • Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
  • Alcohol Misuse screening and counseling
  • Aspirin use for men and women of certain ages
  • Blood Pressure screening for all adults
  • Cholesterol screening for adults of certain ages or at higher risk
  • Colorectal Cancer screening for adults over 50
  • Depression screening for adults
  • Type 2 Diabetes screening for adults with high blood pressure
  • Diet counseling for adults at higher risk for chronic disease
  • HIV screening for all adults at higher risk
  • Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:
  • Hepatitis A
  • Hepatitis B
  • Herpes Zoster
  • Human Papillomavirus
  • Influenza
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Tetanus, Diphtheria, Pertussis
  • Varicella
  • Obesity screening and counseling for all adults
  • Sexually Transmitted Infection prevention counseling for adults at higher risk
  • Tobacco Use screening for all adults and cessation interventions for tobacco users
  • Syphilis screening for all adults at higher risk

Covered Preventive Services for Women, Including Pregnant Women

  • Anemia screening on a routine basis for pregnant women
  • Bacteriuria urinary tract or other infection screening for pregnant women
  • BRCA counseling about genetic testing for women at higher risk
  • Breast Cancer Mammography screenings every 1 to 2 years for women over 40
  • Breast Cancer Chemoprevention counseling for women at higher risk
  • Breast Feeding interventions to support and promote breast feeding
  • Cervical Cancer screening for sexually active women
  • Chlamydia Infection screening for younger women and other women at higher risk
  • Folic Acid supplements for women who may become pregnant
  • Gonorrhea screening for all women at higher risk
  • Hepatitis B screening for pregnant women at their first prenatal visit
  • Osteoporosis screening for women over age 60 depending on risk factors
  • Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
  • Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
  • Syphilis screening for all pregnant women or other women at increased risk

Covered Preventive Services for Children

  • Alcohol and Drug Use assessments for adolescents
  • Autism screening for children at 18 and 24 months
  • Behavioral assessments for children of all ages
  • Cervical Dysplasia screening for sexually active females
  • Congenital Hypothyroidism screening for newborns
  • Developmental screening for children under age 3, and surveillance throughout childhood
  • Dyslipidemia screening for children at higher risk of lipid disorders
  • Fluoride Chemoprevention supplements for children without fluoride in their water source
  • Gonorrhea preventive medication for the eyes of all newborns
  • Hearing screening for all newborns
  • Height, Weight and Body Mass Index measurements for children
  • Hematocrit or Hemoglobin screening for children
  • Hemoglobinopathies or sickle cell screening for newborns
  • HIV screening for adolescents at higher risk
  • Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary: Diphtheria, Tetanus, Pertussis
  • Haemophilus influenzae type b
  • Hepatitis A
  • Hepatitis B
  • Human Papillomavirus
  • Inactivated Poliovirus
  • Influenza
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Rotavirus
  • Varicella
  • Iron supplements for children ages 6 to 12 months at risk for anemia
  • Lead screening for children at risk of exposure
  • Medical History for all children throughout development
  • Obesity screening and counseling
  • Oral Health risk assessment for young children
  • Phenylketonuria (PKU) screening for this genetic disorder in newborns
  • Sexually Transmitted Infection (STI) prevention counseling for adolescents at higher risk
  • Tuberculin testing for children at higher risk of tuberculosis
  • Vision screening for all children

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