• If any preventive care service is dropped from a recommended list from any of the three commissions whose conclusions have been adopted by federal agencies, group health plans may continue to cover the service but require patients to share costs through co-pays, deductibles, or coinsurance.
• Whenever a group health plan decides to make a material change in coverage, including a change in the range of preventive services offered, it must give plan participants 60 days’ notice of the change.
• Group health plans can require cost sharing for recommended preventive care services under the following four circumstances:
  1. When the plan provides coverage for a network of providers and the patient chooses/uses an out-of-network provider;
  2. If a patient chooses a preventive care service that is not on a list of recommended procedures from any of the three commissions that are part of the new regulations;
  3. In most cases, when a patient seeks treatment as a result of a preventive service, but there are exceptions. Notably, if a recommended screening shows a woman to be at high risk for breast cancer, a commission recommends she seek chemoprevention of that cancer.
  4. When a preventive service is provided as part of an office visit but billed separately, or when the office visit was for a reason other than to obtain the preventive service.
• Aside from cost sharing, health plans can limit coverage of preventive services based on the frequency, method, treatment, or setting for the provision of the services, so long as the limitations are determined by using reasonable medical management techniques. Federal guidelines do not specifically bar such limits. For example, if providers recommend a particular screening be done every 2 years, a patient could be assessed a fee if he or she ordered the service every year.

For more information, read the companion article, Agencies Further Define ‘Preventive Services'.