Final Preventive Care Regulations Clarify Many Outstanding Questions

The Departments of Labor, Health and Human Services and Treasury (collectively the "Agencies") have issued final regulations regarding the requirement that non-grandfathered health plans cover preventive services at no charge. These regulations will be effective for calendar year plans on January 1, 2016.

Employers should review their summary plan descriptions to determine what modifications will be necessary to comply with the new rules.

Highlights of the regulations are described below:

  • Plans must provide coverage without cost sharing for preventive services provided for in (i) the Health Resources and Services Administration ("HRSA") Guidelines for Women, (ii) evidence-based items or services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force, (iii) immunizations for routine use that have in effect a recommendation from the Advisory Committee on Immunizations Practices of the Centers for Disease Control and Preventive, and (iv) evidence-informed preventive care and screenings for infants, children, and adolescents, provided for in guidelines supported by HRSA. The complete list of recommendations can be found at: Generally, such services must be covered for the entire plan year, even if there is a change to a particular recommendation or guideline. Notably, plans may continue to impose cost-sharing for additional preventive services or for treatments that result from a recommended preventive service.
  • The regulations retain the "primary purpose test" for determining whether cost-sharing may be imposed on preventive services that are not billed or tracked separately from an office visit.
  • If a plan does not have a network provider that can provide a particular recommended preventive service, the plan must cover (without cost-sharing) the preventive service when performed by an out-of-network provider. Other than this exception, plans may continue to charge for preventive services provided out-of-network.
  • Plans may rely on relevant evidence-based and established reasonable medical management techniques to determine any coverage limitations for preventive services where the recommendation or guideline does not specify the frequency, method, treatment or setting for the provision of the service.
  • The regulations continue to accommodate religious organizations that have an objection to covering contraceptive services and clarify the process for such organizations to notify Health and Human Services of such objection. The regulations also clarify how a closely held for-profit entity may qualify for the religious organization objection.

The information provided is for educational purposes only. This information is from sources we believe to be reliable, but we cannot guarantee or represent that it is accurate or complete. The opinions are those of the writer, and the opinions and information presented are subject to change without notice.

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