The Department of Health and Human Services (HHS), the Department of Labor and the Department of the Treasury July 19 issued new interim final regulations that require health plans and issuers to cover “recommended preventive services” and eliminate  cost-sharing requirements, such as a deductible, copayment or co-insurance, on those measures.  

The regulations go into effect Sept. 17 and generally apply to plans and issuers for plan years beginning on or after Sept. 23, 2010. Grandfathered health plans are not subject to these rules.     

According to the regulations, recommended preventive services include but are not limited to:  blood pressure screening for adults; colorectal cancer screening for adults over 50; breast cancer mammography screenings every 1 to 2 years for women over 40; and autism screening for children at 18 and 24 months. HHS also is developing women’s prevention guidelines which will be issued in August 2011. The complete list of recommendations and guidelines that are required to be covered under the regulations can be found here.  

The regulations clarify the cost-sharing requirements when a recommended preventive service is provided during an office visit.   

For example, if a patient visits a medical office primarily to undergo a recommended preventive service, a plan or issuer may impose cost-sharing requirements on the office visit, as long as the recommended preventive service is billed separately; however, cost-sharing requirements are not allowed to be imposed on the office visit if the recommended preventive service is not billed separately. If the delivery of a recommended preventive measure is not the main purpose of the office visit, then the plan or issuer can impose cost-sharing requirements on the office visit regardless of whether the recommended preventive measure is billed separately.   

Under the regulations, a plan or issuer also may impose cost sharing requirements on a treatment that results from a recommended preventive service, unless that treatment itself is a recommended preventive service.  In addition, a plan or issuer that has a network of providers is not required to provide coverage for recommended preventive services delivered by an out-of-network provider.   

Comments about the regulation may be submitted on or before Sept. 17.  

This article only contains summaries of federal regulatory action and should not be considered a definitive source for the purpose of compliance.  In order to ensure a complete understanding of the requirements outlined on this page, ABC recommends members review official agency guidance and consult with legal counsel whenever necessary.      

The fact sheet is available here: http://www.healthcare.gov/law/about/provisions/services/background.html.   

The regulation is available here: http://www.regulations.gov/search/Regs/home.html#documentDetail?R=0900006480b1c683.