The U.S. Departments of Treasury, Labor, and Health and Human Services have jointly released regulations that address the preventive health care requirements established by the recent health care reform legislation. The regulations apply to plan years beginning on and after September 23, 2010. For calendar year plans, the rules take effect January 1, 2011.
The regulations require health plans to cover specified preventive care services without charging participants any deductible, copayment, or similar cost-sharing amount. These preventive care services are identified in certain guidelines issued by federal governmental health agencies and may be found by clicking here. When new services are added to the list, a plan will have a grace period of one year (and then to the start of the next plan year) to cover those services at 100 percent.
Copayments may be charged for office visits when the preventive care service is billed separately (or tracked as separate encounter data) or when the office visit does not primarily pertain to the preventive care service. A network-based plan may charge copayments or deny coverage altogether for preventive care that is provided out of network.
Unless the applicable guidance on the preventive care services specifies the frequency, method, treatment, or setting for the service, a group health plan may determine them by using reasonable medical management techniques.
Grandfathered health plans are not subject to these rules. Insured plans remain subject to any stricter requirements imposed by states on insurance arrangements.
As the federal health care reform effort gained steam, Ballard Spahr attorneys formed an initiative to monitor and analyze legislative developments. With federal health care reform now a reality, our attorneys are assisting employers in understanding the relevant changes and planning for the future. For more information on the firm’s Health Care Reform Initiative, please click here. If you have any questions, please feel free to contact Edward I. Leeds (215.864.8419 or firstname.lastname@example.org).