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Preventive Items & Services – Clarification with Final Rules

The Affordable Care Act requires non-grandfathered group health plans to cover mandated preventive care services at no cost. The Departments of Labor, the Treasury and Health & Human Services (the “Departments”) recently issued final regulations, effective for plan years beginning on or after October 1, 2015.

Background Info

The preventive services that must be provided without cost sharing fall into four different categories: services with an “A” or “B” recommendation from the U.S. Preventive Services Task Force (USPSTF), vaccines recommended by the Centers for Disease Control and Prevention (CDC), the Bright Futures guidelines developed by the American Academy of Pediatrics with support from the Health Resources and Services Administration (HRSA), and certain women’s services listed in HRSA guidelines (supplementing some of the USPSTF recommendations). The requirement to provide free contraceptive services to women emanates from the latter, and it took effect with the plan year beginning on or after August 1, 2012.

The guidance provides information in the following ways:

  • Clarifies that if a plan that does not have in its network a provider who can provide a particular recommended preventive service, the plan is required to cover the service when performed by an out-of-network provider without cost sharing (i.e., at 100%).
  • Indicates the effective date for changing required preventive services when new guidelines are issued.
  • Rules issued in 2010 provide that if a recommended preventive service does not include specific frequency, method, treatment or setting rules for the provision of that service, a plan sponsor can use reasonable medical management techniques to determine any coverage limitations. The new final rule clarifies that plan sponsors may continue to rely on the relevant clinical evidence base and established reasonable medical management techniques, and do not generally have to defer to the recommendations of a treating physician.
  • Rules issued in 2010 state that plan sponsors may stop providing an item or service once the underlying guideline or recommendation has been changed. The new final rule requires that plan sponsors continue to provide the coverage (without cost sharing) through the end of the plan year, except when the USPSTF has downgraded the recommendation from “A” or “B” to “D” or there is a safety concern. The Departments intend to issue guidance if these types of situations arise.

If there is a change in the guidelines that occurs during a plan year, the group health plan must provide coverage for that item or service until the end of the plan year, except to the extent the change constitutes a downgrade to a “D” rating or the item was part of a safety recall or otherwise poses a significant safety concern. In such circumstances, the Departments will issue guidance addressing the change during the plan year. Note that any such change that occurs outside of renewal and affects the SBC (Summary of Benefits and Coverage) will require 60 days advance notice before the change can be made.

Employers should:

  • Review existing preventive care practices and, in the event network providers do not perform certain required services, ensure the plan provides them at
    100% out-of-network; and
  • Be aware that changes to mandated preventive care services will generally take effect with the following plan year, except when downgraded to “D” or are
    subject to a safety review. The DOL will provide further comment in the event this occurs.

By:  csmith