<nobr>Jul 15, 2010</nobr>

Agencies Release PPACA Interim Final Regulation on Coverage of Preventive Care

The Departments of Treasury, Labor, and Health and Human Services on July 14 issued an interim final regulation to interpret section 2713 of the Patient Protection and Affordable Care Act (PPACA), relating to the provision of preventive care services.

Under the regulation, plans must cover certain preventive care services and must do so without imposing cost-sharing. The new rules, which are effective for plan years beginning on or after September 23, 2010, do NOT apply to grandfathered plans.

According to the regulation, non-grandfathered group health plans must cover certain enumerated preventive care services. Note that the list is somewhat fluid and will be updated from time to time. Plans generally will have at least a year's lead time, however, before they must cover a preventive service item that has been added to the list.

The lists of required items and services may be accessed via the web at:
http://www.healthcare.gov/center/regulations/prevention/recommendations.html.

Required items and services: The required items and services that plans must cover include the following:

• 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;


• 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 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); and


• With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA.

Cost-sharing: The general rule is that a plan may not impose any cost-sharing requirements with respect to the preventive items or services that a plan must cover. In this regard, the regulation makes the following points:

• If a preventive service is billed separately from an office visit, then the plan may impose cost-sharing with respect to the office visit.


• If a preventive service is NOT billed separately from an office visit, and the primary purpose of the office visit was the delivery of the preventive service, then NO cost-sharing may be imposed.


• If a preventive service is NOT billed separately from an office visit, but the primary purpose of the office visit was NOT the delivery of the preventive service, then cost-sharing may be imposed.

Out-of-network services: Plans will not be required to provide coverage for preventive services delivered by an out-of-network provider. Moreover, cost-sharing may be imposed on preventive services delivered by an out-of-network provider.

Miscellaneous: Plans may use "reasonable" medical management techniques to determine coverage limitations if one of the Preventive Services Task Force recommendations does not specify the frequency, method, treatment, or setting for provision of the service.

The regulation provides that a plan is not required to provide coverage or to waive cost-sharing for any item or service that has ceased to be on the recommended list. The regulation goes on to state, however, that section 2715(d)(4) of PPACA requires a plan to give 60 days advance notice before a material modification becomes effective. (The language in the regulation is a little ambiguous on when this notice provision is effective.)

The regulation also notes that the regulatory agencies are developing additional guidelines regarding the utilization of "value-based" insurance designs by plans with respect to preventive care.

Questions or comments on the rule should be addressed to either Gretchen Young, gyoung@eric.org or Adam Solander, asolander@eric.org.

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Interim Final Regulation

Fact Sheet

Recommended Preventive Services

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