Member Article

The U.S. Department of Health and Human Services, the U.S. Department of Labor and the U.S. Department of Treasury have released another set of interim final regulations (the “IFR”) regarding the coverage of preventive care without cost sharing. As with all guidance, the IFR cannot be considered in isolation. Employers should consider how it fits and works with prior guidance, statutes and with the specific situation and benefit options within the employer’s health plan, including the grandfathered status of each such option.

The mandated coverage of preventive care without cost sharing applies to benefit structures that are not grandfathered. The government has developed a Web page that has links to all of the lists of mandated preventive care and describes some of the requirements. The Web page is found here.

Coverage of Preventive Care Without Imposition of Cost Sharing

The IFR attempts to divide whether a cost sharing element is imposed on a service by whether the preventative care service is billed separately from the office visit and, if it is not billed separately, by the primary purpose of the office visit. In addition, the IFR only requires that preventive care be provided without cost sharing by in-network doctors in a plan that has a network of providers; preventive care does not need to be covered without cost sharing if it is obtained from an out-of-network provider.

If the preventive care is billed separately from the office visit, there can be cost sharing (i.e., copayments or co-insurance, etc.) imposed on the office visit. For example, if you go to the doctor and he orders a blood test for your cholesterol and he bills you for the office visit and separately for the lab work, there cannot be any cost sharing with respect to the separately billed lab work for the blood test (because it is a preventive service), but he could impose cost sharing on the office visit (presuming the primary purpose of the office visit is not the cholesterol screening or other preventive care service).

If the office visit is not billed separately from the preventive care, then cost sharing may only be imposed on the office visit if the primary purpose of the office visit is not the delivery of the preventive care item or service (for example, if you go to the doctor for strep throat treatment and get a tetanus vaccine while you are there). It will be interesting to see how they will code the primary purpose of the visit in the electronic transaction and who will make that determination.

If the primary purpose of the office visit is obtaining the preventive care item or service, then there cannot be cost sharing imposed on the office visit if the office visit is billed together with the preventive item or service.

To see the lists of the preventive care required to be covered, please see the website above or you can access the printed lists in one document here.

For more information, please feel free to contact any lawyer in the Employee Benefits Group.

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