Note: Effective for plan years beginning on or after September 23, 2010; applies non-grandfathered plans only. Expanded benefits for women was effective for plan years beginning on or after August 1, 2012.
Non-grandfathered health plans are required to provide coverage for certain preventive services at zero cost to the participant. No deductible, copayment or coinsurance is allowed to be applied to network services.
Preventive services that are required to be covered with no cost-sharing fall into the following categories:
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 (Task Force) with respect to the individual involved.
Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved.
With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA).
With respect to women, evidence informed preventive care and screening provided for in comprehensive guidelines supported by HRSA (not otherwise addressed by the recommendations of the Task Force).
Preventive services are broken down into 3 areas: adults, women, and children.
If a recommended preventive service or item is not billed separately (or is not tracked as individual encounter separately) from an ofﬁce visit and the primary purpose of the ofﬁce visit is the delivery of such a service or item, then a plan may not impose cost-sharing requirements with respect to the ofﬁce visit.
If a recommended preventive service is billed separately from an ofﬁce visit, or if the recommended preventive service is not billed separately and the primary purpose of the ofﬁce visit is not delivery of the recommended preventive service, then a plan may impose cost-sharing with respect to the ofﬁce visit.
Plans that have a network of providers are not required to provide coverage for and may impose cost-sharing requirements for recommended preventive services delivered by an out-of-network provider.
For any service that does not have a network provider available, coverage will need to be provided at the network benefit level for out-of-network services for that specific benefit.
Plans may use reasonable medical management techniques to determine the frequency, method, treatment, or setting for the recommended preventive services to the extent these are not speciﬁed in the recommendations or guidelines.
Plans can also impose cost-sharing for a treatment that is not a recommended preventive service under these regulations, even if the treatment resulted from a recommended preventive service.