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:
Preventive services are broken down into 3 areas: adults, women, and children.
For Adults – these include the following
For Women – these include the following in addition to those listed above (not all-inclusive):
For Children – these include the following
More detailed information along with a complete list can be found at: https://www.healthcare.gov/coverage/preventive-care-benefits/
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.