Understanding the Preventive Services Rule Changes

September 2010, Vol 1, No 4

On July 14, 2010, the Departments of Treasury, Labor, and Health and Human Services issued interim final rules for group health plans and health insurance issuers to provide detail on how those entities are to cover the preventive services required under the Patient Protection and Affordable Care Act (PPACA). It is important for readers of this publication to be aware of these rules and to understand how these changes will impact their business and patient care going forward.

PPACA requires insured and selfinsured group health plans as well as health insurance issuers in the group and individual markets to provide coverage of, and eliminate cost-sharing for, the following preventive services:

  1. Services/items with an ‘A’ or ‘B’ rating from the US Preventive Services Task Force (USPSTF). Cancer-specific recommendations in this category include BRCA screening and counseling; breast cancer preventive medications; breast, cervical, and colorectal cancer screening; and tobacco use counseling.
  2. Immunizations with recommendations from the Advisory Committee on Immunization Practices of the CDC;
  3. Preventive care and screening for infants, children, and adolescents provided by Health Resources and Services Administration (HRSA) guidelines; and
  4. With respect to women, preventive care and screening provided by HRSA (except breast cancer screening recommendations issued in November 2009).
  5. These provisions, however, do not apply to grandfathered plans, which are plans that existed at the time of enactment. According to estimates by the Departments (based on Kaiser data), 82% of large employers and 70% of small employers will remain grandfathered in 2011. By 2013, 55% of large employers and 34% of small employers will remain grandfathered. So it is unclear how many plans will be affected by this provision because of grandfathering and the fact that some plans already provide coverage of, and eliminate cost-sharing for, preventive services (either by State law, or voluntarily).

Interpreting the Rules

So what will the Interim Final Rules on Preventive Services mean for practitioners and payers? First, if preventive services are billed jointly with an office visit, copays may be imposed if the primary purpose of the visit was something other than the preventive services. However, if the primary purpose was to obtain preventive services, copays are not allowed. Note that “primary purpose” is not defined, which could lead to confusion regarding billing for such visits. In addition, if preventive services are billed separately, the copay is waived for such service (but copays for the office visit still apply).

On the health plan side, plans are not required to provide coverage of, and may impose cost-sharing for, preventive services provided out-of-network. Also, if a recommendation/guideline for preventive services fails to specify the frequency, method, treatment, or setting, the plan may use “reasonable medical management” to determine coverage rules.

The provision applies to plan years beginning on or after September 23, 2010, or the first plan year beginning on or after the date that is 1 year after the recommendation/guideline goes into effect. For an employer plan beginning on July 1, 2011, the employer would not have to provide coverage of, and eliminate cost sharing for, that service until July 1, 2012.

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