Understanding Employee Benefits and key developments in the employee benefits field and items of interest to our clients. MORE

This is the seventh in a series of articles about health care reform.

Q.1 What do the new rules require?
A.1 The new rules require nongrandfathered group health plans and group and individual health insurance polices see previous grandfathered article to provide certain preventive services to enrollees under the plan without cost-sharing. Generally speaking, this means that preventive care must be provided without charges such as co-pays, co-insurance or deductibles. However, see Question 3 for some exceptions to this general rule.

Q.2 What services are considered preventive for purposes of this mandate?
A.2 The regulations pull in recommendations from existing governmental agencies to determine what constitutes preventive care, specifically:

-Services with a rating of A or B in the current recommendations of the United States Preventive Services Task Force,

-Routine immunizations for children, adolescents and adults as recommended by the Centers for Disease Control and Prevention,

-Preventive care and screenings for infants, children and adolescents under guidelines supported by the Health Resources and Services Administration (HRSA), and

-Screenings for women that are being developed by the Department of Health and Human Services and are expected to be issued no later than August 1, 2011.

These guidelines will be available in a Web site that plans can review annually. A newly recommended service will not be required to be covered until the plan year beginning 12 months after the recommended service is added to the list. Therefore, plans would have to update their preventive care offerings only once a year.

Q.3 Are there situations in which a plan can charge enrollees for preventive services?
A.3 There are a couple situations in which a plan can impose patient cost-sharing charges for preventive services.

First, a plan can limit the preventive services covered without charge to in-network providers. Therefore, enrollees obtaining preventive services from out-of-network providers can be required to pay the ordinary out-of-network deductibles and other cost-sharing charges.

Second, there is a special rule for charging for the office visit. According to the regulations, if the primary purpose of an office visit is something other than preventive care but an enrollee receives preventive care as part of the office visit, the enrollee can be required to pay for the office visit. For example, if an enrollee sees a physician for the primary purpose of treating the enrollee’s diabetes and, if in connection with that visit, the enrollee’s blood pressure is taken, the plan can require the enrollee to pay for the office visit even though blood pressure monitoring is generally considered preventive care. On the other hand, if the primary purpose of the office visit is preventive care, the plan cannot impose a cost-sharing charge on the enrollee for the office visit unless the plan imposes charges separately for the preventive services and the office visit. The regulations give the example of an office visit in which the enrollee receives a cholesterol screening test that is separately billed. In that situation, the plan cannot impose cost-sharing charges on the enrollee for the cholesterol test but can impose such charges for the office visit.

It is difficult to know how often this office visit charge can be imposed with respect to preventive services. Some of the items covered as preventive services include blood pressure screening (as mentioned above), obesity and tobacco counseling, screening for depression and counseling for a healthy diet. Currently, most providers do not generally bill these items separately from the office visit itself. If that is the case, then it is unlikely that the plan could require the enrollee to pay anything for an office visit, the primary purpose of which was preventive services, even if certain services (such as a cholesterol screening blood test) are separately billed. On the other hand, if an enrollee schedules a preventive visit, then raises during the visit a medical concern that results in a diagnosis and treatment (e.g., a nagging cough or sore throat that is diagnosed and treated during the visit), there may be disputes about the “primary purpose” of the visit. Enrollees who disagree with the plan’s determination of the primary purpose of a visit may appeal that decision under the plan’s claims review procedures.

Q.4 Can a plan impose limits on the frequency, method, treatment or setting for preventive care?
A.4 Yes. The regulations allow a plan to impose reasonable medical management techniques with respect to preventive services. Therefore, a plan can limit the number of screenings it will cover without additional charges to the enrollee and can limit the preventive coverage to in-network providers.

Q.5 What if the guidelines change and a particular service is no longer a preventive service? Can the plan drop that service?
A.5 A plan is not required to provide as a free preventive service a service that the government no longer lists as preventive on its Web site. However, under health care reform, a reduction in plan benefits can be imposed only after 60 days’ advance notice is given to the enrollee. Therefore, a plan will have to give that advance notice before dropping the benefit or imposing cost sharing for it.

Q.6 When is this new mandate effective?
A.6 For nongrandfathered plans, these new rules are effective for plan years/policy years beginning on or after September 23, 2010, or as of January 1, 2011, for calendar-year plans.


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