First-Dollar Coverage of Designated Preventive Services
The Facts
Health care reform requires non-grandfathered group health plans and health insurance coverage to provide first-dollar coverage of certain preventive services furnished by in-network providers. This requirement is effective with the first day of the first plan / policy year beginning on or after September 23, 2010.
Coverage is mandatory for four general categories of preventive services, referred to as recommended preventive services. The U.S. Department of Health and Human Services (HHS) will maintain a complete and up-to-date list of recommended preventive services on its website.
Coverage is not required for recommended preventive services furnished by out-of-network providers, and cost-sharing obligations also may imposed. HHS also has adopted regulations addressing cost-sharing requirements for office visits (and other health care services) furnished at the same time as a recommended preventive service.
What’s at Stake
Group health plans and health insurance issuers offering non-grandfathered plans and policies need to evaluate their plans / policies to assess whether changes are needed, both to comply with this new coverage mandate and to promote in-network provider utilization.
Steps to Consider
Medical management techniques to administer benefits for recommended preventive services are permitted, and group health plans and health insurance issuers will want to consider what techniques may be appropriate. An additional consideration is whether the claims submission and payment provisions need to be modified to implement the cost-sharing regulations for office visits and other health care services provided at the same time as recommended preventive services.
