Regulations Issued on Preventive Services

As part of ongoing guidance on this spring’s health reform legislation, the IRS, Department of Labor, and Department of Health and Human Services have issued interim final and proposed regulations implementing the preventive health services rules in the acts (T.D. 9493; REG-120391-10).

The Patient Protection and Affordable Care Act (P.L. 111-148) and the Health Care and Education Reconciliation Act (P.L. 111-152) amended and added to certain provisions of the Public Health Service Act (PHS Act) relating to group health plans and health insurance issuers in the group and individual markets. The Patient Protection Act added section 715(a)(1) to the Employee Retirement Income Security Act (ERISA) and Sec. 9815(a)(1) to incorporate the provisions of part A of title XXVII of the PHS Act into ERISA and the Code and make them applicable to group health plans and health insurance issuers providing health insurance coverage in connection with group health plans.

The PHS Act requires group health plans and health insurance issuers offering group or individual health insurance coverage to provide benefits for and prohibit the imposition of cost-sharing requirements with respect to:

• Certain evidence-based items or services (receiving an A or B level recommendation from the United States Preventive Services Task Force).
• Immunizations for routine use in children, adolescents and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.
• With respect to infants, children and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA).
• Evidence-informed preventive care and screening for women provided for in comprehensive guidelines supported by HRSA (not otherwise addressed by the recommendations of the United States Preventive Services Task Force).

The interim final regulations clarify the cost-sharing requirements when a recommended preventive service is provided during an office visit. Examples in the interim final regulations illustrate their provisions.

The interim final regulations make clear that a plan or issuer is not required to provide coverage for recommended preventive services delivered by an out-of-network provider. Such a plan or issuer may also impose cost-sharing requirements for recommended preventive services delivered by an out-of-network provider.

The interim final regulations also clarify that a plan or issuer continues to have the option to cover preventive services in addition to those required to be covered by PHS Act section 2713. For such additional preventive services, a plan or issuer may impose cost-sharing requirements at its discretion. Moreover, a plan or issuer may impose cost-sharing requirements for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.

The regulations are effective September 17, 2010.