Employee Benefits Compliance, Preventive Services

“First-dollar Coverage” of Preventive Services

Quick Summary of “First-dollar coverage” of Preventive Services 

WHATNon-grandfathered group health plans and individual policies must provide “first-dollar coverage” for specified preventive services (listed below) and cannot require participants to pay any share of the cost of these services (e.g., deductibles, co-pays, co-insurance).
WHENAs of January 1, 2011 for calendar-year plans and policies.  For preventive services specified after September 23, 2009, compliance is required as of the plan or policy year beginning one year after the guideline or recommendation is issued (e.g., August 1, 2012 for guidance issued August 1, 2011 on women’s preventive services).
WHO’s AFFECTEDNon-grandfathered insured & self-funded plans and individual policies; plan sponsors and insurance issuers.  Does not apply to grandfathered plans.


Public Health Service Act (PHSA) section 2713


The Patient Protection and Affordable Care Act (PPACA) requires non-grandfathered group health plans and individual policies to provide first-dollar coverage of “preventive services” as defined by the federal government (see list below).  This may be a broader definition of “preventive services” than the definition the plan would use on its own.  “First-dollar coverage” means the plan must pay for preventive services even before the participant has met his/her deductible, and the participant cannot be required to pay any co-payment, coinsurance or other cost-sharing.  There are some limitations, such as if the preventive services are provided by out-of-network providers.  Also, plans can use reasonable medical management techniques.

To Which Preventive Services does this Requirement Apply?

  • Items or services with an A or B rating recommended by the United States Preventive Services Task Force
  • Immunizations for routine use in children, adolescents, or adults recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention
  • Preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children, and adolescents
  • Preventive care and screenings for women, provided for in interim final regulations (IFR) and guidance issued August 1, 2011 by HHS/HRSA, after the Institute of Medicine (IOM) issued guidelines July 19, 2011. (The list of preventive services is at http://www.hrsa.gov/womensguidelines/ )

What are some Examples of Preventive Services?

  • Blood pressure, diabetes and cholesterol tests
  • Many types of cancer screenings, including:
    • Annual mammograms for women over 40, and other services to prevent breast cancer
    • Regular Pap smears to screen for cervical cancer and coverage for the HPV vaccine
    • Tobacco cessation interventions, such as counseling or medication to help individuals quit
    • Screening tests for colon cancer for adults over 50.
  • Counseling from health care providers on quitting smoking, losing weight, eating better, treating depression, and reducing alcohol use
  • Routine vaccines for diseases such as measles, polio, or meningitis
  • Flu and pneumonia shots
  • Counseling, screening, and vaccines for healthy pregnancies – including the following services:
    • Screening for iron deficiency, hepatitis B, Rh incompatibility, and bacteriuria
    • Special counseling from a doctor to help pregnant women quit smoking and alcohol use
    • Counseling to support breast-feeding and help nursing mothers
  • Regular well-baby and well-child visits from birth to age 21 – including a doctor’s visit every few months for a young baby, and an annual visit until age 21, covering preventive services such as:
    • Physical exam and measurements, and developmental assessments
    • Vision and hearing screening, and oral health risk assessments
    • Screenings for hemoglobin level, lead, tuberculin, and other tests
    • Screenings and counseling to prevent, detect, and treat common childhood problems like obesity, depression and dental cavities and anemia
  • Preventive care and screenings for women – including the following services:
    • Well-woman visits
    • Screening for gestational diabetes
    • Human Papillomavirus (HPV) testing
    • Counseling for sexually transmitted infections
    • Counseling and screenings for human immune-deficiency virus
    • All FDA-approved contraceptive methods and counseling
    • Breastfeeding support, supplies and counseling
    • Screening and counseling for domestic violence.

Are There Any Limitations or Exceptions?

  • Preventive Services Provided by Out of Network Providers
    If a plan or health insurance coverage has network providers, it is not required to provide coverage for recommended preventive services provided by an out-of-network provider, and if it does provide such coverage, it may impose cost-sharing requirements on participants who receive recommended preventive services from out-of-network providers.
  • Use of Reasonable Medical Management Techniques
    The interim final regulations allow a plan or carrier to use “reasonable” medical management techniques to determine the frequency, method, treatment or setting for which it will cover a recommended preventive service with no cost-sharing, if the guidance or recommendation for that preventive service does not specify the frequency, method, treatment, or setting for the provision of that service.

When is this Requirement Effective?

For preventive services specified as of September 23, 2009, plans were required to comply as of the first plan year beginning on or after September 23, 2010 (as of January 1, 2011 for calendar-year plans and policies.)  For preventive services specified after September 23, 2009, plans must comply as of the plan year beginning one year after the guideline or recommendation is issued (e.g., August 1, 2012 for women’s preventive services).