• Evidence-based items or services that have a rating of A or B in the current recommendations of the United States Preventive Services Task Force for the individual involved (Note: recommendations of the United States Preventive Services Task Force on breast cancer screening, mammography, and prevention issued in or around November 2009 are not considered to be current);
• 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 for the individual involved (for this purpose, a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention);
• For infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA);
• For women, if not included by the first item above, evidence informed preventive care and screenings provided for in comprehensive guidelines supported by the HRSA.

A plan may provide coverage for services in addition to those recommended by U.S. Preventive Services Task Force and may deny coverage for services that are not recommended by the Task Force

When are new recommendations or guidelines subject to the cost-sharing ban? HHS is authorized to set a minimum interval of not less than 1 year between when a preventive services recommendation or guideline is issued and the plan year for which the recommendation or guideline applies. Interim final regulation provide that coverage must be provided for plan years beginning on or after the later of September 23, 2010, or 1 year after the date a recommendation or guideline is issued. Thus, recommendations and guidelines issued before September 23, 2009 must be provided for plan years beginning on or after September 23, 2010.

A recommendation or guideline of the Task Force is considered to be issued on the last day of the month on which the Task Force publishes or otherwise releases the recommendation. A recommendation or guideline of the Advisory Committee is considered to be issued on the date on which it is adopted by the Director of the Centers for Disease Control and Prevention. A recommendation or guideline in the comprehensive guidelines supported by HRSA is considered to be issued on the date on which it is accepted by the administrator of HRSA or, if applicable, adopted by the Secretary of HHS.

For recommendations and guidelines adopted after September 23, 2009, the information at http://www.HealthCare.gov/center/ regulations/prevention.html will be updated on an ongoing basis and will include the date on which the recommendation or guideline was accepted or adopted.

Cost-sharing requirements and office visits. Because an office visit where preventative services are provided may include other services, the interim final regulations provide the following clarifications of the cost-sharing requirements when a recommended preventive service is provided during an office visit:

• If a recommended preventive service is billed separately (or is tracked as individual encounter data separately) from an office visit, a plan or insurer may impose cost-sharing requirements with respect to the office visit.
  
• If a recommended preventive service is not billed separately (or is not tracked as individual encounter data separately) from an office visit and the primary purpose of the office visit is the preventive service, a plan or insurer may not impose cost-sharing requirements for the office visit.
  
• If a recommended preventive service is not billed separately (or is not tracked as individual encounter data separately) from an office visit and the primary purpose of the office visit is not the preventive service, a plan or insurer may impose cost-sharing requirements for the office visit.
  
• Tracking individual encounter data applies to plans that use capitation or similar payment arrangements and do not bill individually for items and services.

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

Coverage limitations. The interim final regulations provide that 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, the plan or insurer can use reasonable medical management techniques to determine any coverage limitations. The use of reasonable medical management techniques allows plans and issuers to adapt such recommendations and guidelines to the coverage of specific items and services where cost sharing must be waived. Thus, a plan or insurer may rely on established techniques and the relevant evidence base to determine the frequency, method, treatment, or setting for which a recommended preventive service will be available without cost-sharing when not specified in a recommendation or guideline.

Related articles:

• Healthcare Reform Update: Ban on Annual and Lifetime Limits
• Regulations for Early Retiree Coverage Program Established by Government
• Healthcare Reform Update: Dependent Coverage to Age 26

Visit Healthcare Reform: A Resource Center for Employers for more articles and guidance on how the healthcare reform may affect your organization.