The Patient Protection and Affordable Care Act, referred to as healthcare reform, provides that new benefit plans and their issuers cover certain preventive care services provided in network without charging patients any co-pays or deductibles. But until interim regulations were issued, it was hard to tell what kinds of such services were included.For a Limited Time receive a
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Download NowAgencies base guidelines on other sources. In mid-July, the Departments of Health and Human Services, Labor, and Treasury issued regulations to define preventive care services. Remember that these guidelines don’t apply to grandfathered plans but only to new plans, fully insured or self-insured, beginning on or after September 23, 2010 (with most plan years beginning January 1, 2011). Remember as well that any recommendation or guideline for a preventive service that was issued less than a year before the employer’s plan year begins need not be covered until the following plan year.
Basically, the agencies combined the recommendations of three other sources. They are the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP), and the Health Resources and Services Administration (HRSA). In that order, here’s a sampling of those groups’ recommendations:
- USPSTF: The task force offers a chart of services targeted primarily to adults and is divided into Grades A and B according to how crucial the group feels they are. Grade A includes screenings for blood pressure, cervical cancer, cholesterol, colorectal cancer, HIV, and hepatitis B; aspirin use to prevent cardiovascular disease; and tobacco and alcohol use counseling. Grade B includes screening teens for depression and promoting and supporting breastfeeding. A relatively new recommendation is screening and counseling for obesity in children.
- ACIP: The agencies adopted this committee’s four sets of recommended immunizations for various age groups—0 through 6, 7 through 18, adults, and a catch-up schedule for ages 4 months to 18 years if a child falls behind in immunizations. These include vaccines against pneumococcal pneumonia, measles/mumps/rubella/varicella, influenza, human papillomavirus, tetanus boosters for adults, and many, many other immunizations.
- HRSA: The agencies incorporated this committee’s recommendations for pediatric care for infants (sometimes called well-baby care), children, and adolescents. Covered services include measurements of height, weight, length, and body mass index; vision and hearing tests; assessments of development and behavior; and several physical exams, including screening for lead. HRSA also recommends additional preventive care for adult women, such as mammograms and clinical breast exams.
These are the minimum services that must be offered without cost-sharing to participants in healthcare plans. But a plan may provide coverage for additional preventive services and may deny coverage for services that are not recommended by USPSTF.
For more information, read the companion article, Preventive Care Services Regulations: Qualifications and Exceptions.
Visit Healthcare Reform: A Resource Center for Employers on HR.BLR.com for additional guidance on healthcare reform.