Preventive Services Mandate
A non-grandfathered plan must comply with the following under the preventive services mandate:
- Plans must provide coverage at no cost (no copays, deductibles or coinsurance can be imposed) for certain in-network "recommended preventive services", including preventive immunizations.
- If a service is identified as being a recommended preventive service, the plan must provide coverage of that service.
- A plan may impose cost-sharing requirements on coverage of recommended preventive services delivered by an out-of-network provider provided that the member has access to in-network providers. If a member does not have access to an in-network provider, the plan must cover the out-of-network services with no cost sharing.
A complete list of the recommended preventive services that are required to be covered without cost sharing can be found at
https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations but can be broken into the following categories:
- Evidence-based items or services with an "A" or "B" rating from the U.S. Preventive Services Task Force (USPSTF)
- Immunizations for routine use in children, adolescents and adults with a recommendation in effect from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention
- Evidence-informed preventive care screenings for infants, children and adolescents provided in guidelines supported by the Health Resources and Services Administration (HRSA)
- Evidence-informed preventive care and screening for women provided in guidelines supported by HRSA and not otherwise addressed by the USPSTF.
Plans will need to review this website at least once annually to ensure full compliance as the list of recommended preventive services is updated periodically. Any recommendation that is added or changed throughout the year is not required to be complied with until the first plan year beginning on or after the date that is one year after the new recommendation is added.
There are some important things to keep in mind when covering preventive services:
- A plan may impose cost-sharing for a treatment not included in the specified recommendations, even if the treatment is deemed a preventive service.
- A plan may use reasonable medical management techniques to determine the frequency, method, treatment or setting for a required preventive care item or service to the extent not specified in the recommendation or guidelines.
- A few special rules apply to preventive services delivered in connection with office visits:
o Cost-sharing may not be imposed for the cost of the office visit if the primary purpose of the office visit is the recommended preventive service and the recommended preventive service is
NOT billed or itemized separately.
o Cost-sharing may be imposed for the cost of the office visit but not for the preventive services if the recommended preventive service is billed or itemized separately from the office visit.
o Cost-sharing may be imposed for the cost of the office visit if the preventive service is not billed or itemized separately but the primary purpose of the office visit is not the delivery of such
an item or service.
Impact to High Deductible Health Plans
Medical benefits may not be paid by a HDHP until the member's deductible is met in full. This means there can be no deductible-waived benefits under the plan, or benefits subject to copays only with the exception of preventive services. Qualified HDHPs can pay for preventive services before participating employees meet their deductibles as the Affordable Care Act mandates that certain preventive services be paid by the plan at no cost sharing to the employee.
Preventive care is not precisely defined for HDHP purposes but the IRS says it includes, but is not limited to the following:
- Periodic health evaluations, including tests and diagnostic procedures ordered in connection with routine examinations, such as annual physicals.
- Routine prenatal and well-child care.
- Child and adult immunizations.
- Tobacco cessation programs.
- Obesity weight-loss programs.
- Screening services
IRS guidance also provides that "preventive care does not generally include any service or benefit intended to treat an existing illness, injury, or condition".
Plans that fail to comply with the Preventive Services mandate will be subject to an excise tax of $100 per day per affected individual.
This content is being provided as an informational tool. It is believed to be accurate at the time of posting and is subject to change. It is recommended that plans consult with their own experts or counsel to review all applicable federal and state legal requirements that may apply to their group health plan. By providing this information, Meritain Health is not exercising discretionary authority or assuming a plan fiduciary role, nor is Meritain Health providing legal advice.