Administration Issues Regulations on First-Dollar Preventive Care

Employers may limit first-dollar coverage to in-network providers

By Stephen Miller Jul 15, 2010

The U.S. Departments of Health and Human Services (HHS), Labor, and the Treasury issued Preventive Regulations on July 14, 2010, requiring new (i.e., "non-grandfathered") health plans to cover listed preventive services and eliminate cost-sharing requirements for such services. The regulations implement preventive care provisions of the Patient Protection and Affordable Care Act, the health care reform overhaul enacted in March 2010.

The regulations apply to those who enroll in non-grandfathered health plans after Sept. 23, 2010 (in effect, Jan. 1, 2010, for calendar year plans). Grandfathered plans—those plans that do not, for example, increase co-insurance requirements or boost employee premium contributions by more than five percentage points—are exempt from the mandate to provide full first-dollar coverage for preventive services.

The regulations are intended to provide easier access to services such as blood pressure, diabetes, and cholesterol tests; many cancer screenings; routine vaccinations; pre-natal care; and regular wellness visits for infants and children. Under the regulations, new health plans must cover these preventive services without charging patients a co-payment, co-insurance or deductible for preventive services delivered by a network provider. Employers will be able to continue to require cost-sharing on preventive services employees receive from out-of-network providers.

“Today, too many Americans do not get the high-quality preventive care they need to stay healthy, avoid or delay the onset of disease, lead productive lives, and reduce health care costs,” said HHS Secretary Kathleen Sebelius, in a statement.

Chronic diseases, such as heart disease, cancer, and diabetes, are responsible for 7 of 10 deaths among Americans each year, account for 75 percent of the nation’s health spending and often are preventable, according to a release by HHS. Nationally, Americans use preventive services at about half the recommended rate, HHS estimates.

Making the Grade

Among the health care services covered by the new regulations are:

Preventive services. The U.S. Preventive Services Task Force rates preventive services, and those receiving a grade of A or B are covered under these rules, including (with some limitations) breast and colon cancer screenings, screening for vitamin deficiencies during pregnancy, screenings for diabetes, high cholesterol and high blood pressure, and tobacco cessation counseling. A list of covered preventive services for adults can be found at the government's website, here.

Vaccines.New health plans will also be required to cover a set of standard vaccines recommended by the Advisory Committee on Immunization Practices ranging from routine childhood immunizations to periodic tetanus shots for adults.

Pediatric care. New health plans must cover preventive care for children recommended under the Bright Futures guidelines, developed by the Health Resources and Services Administration with the American Academy of Pediatrics. These guidelines provide pediatricians and other health care professionals with recommendations on the services they should provide to children up to age 21, including regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity and help children maintain a healthy weight.

Prevention for women. Health plans must cover preventive care provided to women under the U.S. Preventive Services Task Force listed services in the new regulations, which includes anemia and infection screening for pregnant women, and breast cancer mammography screenings every 1 to 2 years for women over 40,In addition, new guidelines on required preventive services are being developed by an independent group of experts, including doctors, nurses, and scientists, which are expected to be issued by Aug. 1, 2011.

While prescription contraceptives are not listed as a preventive service under the new regulations, the Planned Parenthood Federation of America announced that it is working to have contraceptives covered on a first-dollar basis as part of regulations on women's health.

Stephen Miller is an online editor/manager for SHRM.

Related Articles:

U.S. Agencies Clarify Restrictions on “Grandfathered” Health Plans, HR News, June 2010

Grandfathered Status Rule’s Impact on Group Health Care Weighed, SHRM Online Legal Issues, June 2010

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SHRM Online Health Care Reform web page

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