Employee Benefits Compliance, Preventive Services

Preventive Services

Non-grandfathered health plans must provide first-dollar coverage of “preventive services” as defined below.  This could be a broader definition of “preventive services” than the definition the plan would use on its own.  “First-dollar coverage” means no participant cost-sharing, co-payment or coinsurance for preventive services, and the plan must pay the first-dollar coverage even before the participant has met his/her deductible.  There are some limitations, such as if the preventive services are provided by out-of-network providers, and use of reasonable medical management techniques.  See section 2 below.


Preventive services:

  • Items or services with an A or B rating recommended by the United States Preventive Services Task Force, with respect to the individual involved;
  • 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, with respect to the individual involved;
  • Preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) for infants, children, and adolescents;  and
  • Preventive care and screenings for women, provided for in guidelines that were issued August 1, 2011 by HHS/HRSA.

Examples of preventive services:

The following information is from:http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html, 11/29/11

  1. Blood pressure, diabetes, and cholesterol tests;
  2. Many types of cancer screenings;The new regulations ensure that new health plans offer coverage without cost-sharing for a variety of important cancer prevention tools. These include:
  • Preventing breast cancer: Annual mammograms for women over 40.  Other services to prevent breast cancer will also be covered, including a referral to genetic counseling and a discussion of chemoprevention for certain women at increased risk.
  • Preventing cervical cancer: Regular Pap smears to screen for cervical cancer and coverage for the HPV vaccine that can prevent cases of cervical cancer.
  • Tobacco cessation interventions, such as counseling or medication to help individuals quit.
  • Preventing colon cancer: Screening tests for colon cancer for adults over 50.
  1. Counseling from health care providers on quitting smoking, losing weight, eating better, treating depression, and reducing alcohol use;
  2. Routine vaccines for diseases such as measles, polio, or meningitis;
  3. Flu and pneumonia shots;
  4. Counseling, screening, and vaccines for healthy pregnancies;These services include:
  • Screening for conditions that can harm pregnant women or their babies, including iron deficiency, hepatitis B, a pregnancy related immune condition called Rh incompatibility, and a bacterial infection called bacteriuria
  • Special, pregnancy-tailored counseling from a doctor that will help pregnant women quit smoking and avoid alcohol use
  • Counseling to support breast-feeding and help nursing mothers
  1. Regular well-baby and well-child visits from birth to age 21.  This includes a doctor’s visit every few months when your baby is young, and a visit every year until your child is age 21.  These visits will cover a comprehensive array of preventive health services:
  • Physical exam and measurements
  • Vision and hearing screening
  • Oral health risk assessments
  • Developmental assessments to identify any development problems
  • Screenings for hemoglobin level, lead, tuberculin, and other tests
  • Counseling and guidance from your doctor about your child’s health development
  • Screenings and counseling to prevent, detect, and treat common childhood problems like:
    • obesity to help children maintain a healthy weight
    • depression among adolescent children
    • dental cavities and anemia
  1. Preventive care and screenings for women.  The Institute of Medicine (IOM) issued guidelines July 19, 2011, and HHS/HRSA issued an amendment to the interim final regulations (IFR) and guidance on August 1, 2011.  The list of women’s preventive services that must be covered (in plan years beginning on or after August 1, 2012) is at http://www.hrsa.gov/womensguidelines/  and includes the following:
  • 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.

Additional information is in the Preamble to the Regulations, and at: http://www.healthcare.gov/center/regulations/prevention.html (which will be updated on an ongoing basis).


Preventive Services Provided by Out of Network Providers

If a plan or health insurance coverage has network providers, it can limit coverage for preventive services to only those services provided by in-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 also provide that a plan or issuer may use reasonable medical management techniques to determine any coverage limitations if a recommendation or guideline for a recommended preventive service does not specify the frequency, method, treatment, or setting for the provision of that service.  In such case a plan or health insurance issuer may rely on established techniques and the relevant evidence base to set the frequency, method, treatment, or setting for which a recommended preventive service will be covered without cost-sharing requirements.

Request for Comments on Value-Based Insurance Designs

The preamble to the interim final regulations also invited comments on value-based insurance designs (VBID). In general, VBID includes the provision of information and incentives for consumers that promote access to and use of higher value providers, treatments, and services.