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The Departments of Treasury, Labor and Health and Human Services have jointly issued interim final regulations requiring the coverage of preventive health services.

The relevant provisions of the interim final regulations that affect group health plans, released on July 14, 2010, are summarized below.

Required Coverage of Recommended Preventive Services

A group health plan must provide coverage for the following “recommended preventive services” without any cost-sharing requirements (e.g., copayment, insurance or deductible):

• evidence-based items or services rated A or B by the US Preventive Services Task Force
• immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and
• evidence-informed care and screenings for women and children under the guidelines of the Health Resources and Services Administration

Examples of recommended preventative services include obesity screening and counseling for children and vaccines or immunizations for miningococcus, human papillomavirus, influenza, pneumococcus, measles, mumps, rubella and varicella.  The complete list of recommended preventive services can be found here.

Effective Date.  Coverage of a recommended preventive service must be provided beginning on or after September 23, 2010, or one year after the date a recommendation or guideline is issued by the applicable task force, committee or agency.  Thus, recommendations and guidelines issued before September 23, 2009, including the examples listed above, must be provided for plan years beginning on or after September 23, 2010.

Grandfathered Plans.  The interim final regulations requiring coverage of recommended preventative services without cost-sharing requirements do not apply to grandfathered health plans.  For more information on whether a group health plan is a grandfathered plan, read here. 

Other Preventive Services.  Nothing in the interim final regulations prohibits a plan from covering other preventive services in addition to the recommended preventive services.  If additional preventive services are covered, a plan may impose cost-sharing requirements on such services.  Moreover, a plan pay impose cost-sharing requirements for treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.  Additionally, if an item or services ceases to be a recommended preventive service, a plan is not required to provide coverage or waive cost-sharing requirements for such item or service.

Cost-Sharing for Office Visits

The interim final regulations limit the cost-sharing requirements that may be imposed when a recommended preventative service is provided during an office visit, as follows:

• If a recommended preventive service is billed separately from an office visit, then a plan may impose cost-sharing requirements with respect to the office visit
• 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 service, then a plan may not impose cost-sharing requirements with respect to the office visit, and
• 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 service, then a plan may impose cost-sharing requirements with respect to the office visit

No Out-of-Network Requirement

The interim final regulations clarify that a plan is not required to provide coverage for recommended preventive services delivered by an out-of-network provider.  Thus, a plan may impose cost-sharing requirements for recommended preventive services by an out-of-network provider.

Permitted Coverage Limitations

If a recommendation or guideline for a recommended preventive service does not specify the frequency, method, treatment or setting for the provision of that service, the plan can use reasonable medical management techniques to determine any coverage limitations.  A plan may rely on established techniques and the relevant evidence base to determine the frequency, method, treatment or setting for which a recommended preventive service will be available without cost-sharing requirements to the extent not specified in a recommendation or guideline.

The interim final regulations are complex and this Alert is intended only as a brief overview.  If you have any questions about this Alert, please contact any of the individuals listed below:

In Chicago:

Anne M. Pachciarek

In Washington, DC:

Mark Muedeking

Rita M. Patel

Julia T. Kovacs

In San Francisco:

Mark H. Boxer

David F. Boyle

If you have any questions about the health care reforms generally, please contact any of the members of our Employee Benefits and Executive Compensation Group.

To see our library of writings about the health care reforms, please click here.

For more information on DLA Piper’s Health Care practice generally, please contact: 

Senator Tom Daschle

Kimberly K. Egan

Stephen L. Goff