The preventive care coverage requirement applies to both fully insured and ASO plans. However, it does not apply to Grandfathered Plans. It becomes effective for plan years beginning on or after September 23, 2010.

Under the preventive care coverage provision, plans and issuers are required to provide coverage for the recommended preventive services described below.

• Items or services that have an 'A' or 'B' rating in the current recommendations of the U.S. Preventive Services Task Force (USPSTF) with respect to the individual involved.
• Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved. A recommendation of ACIP is considered to be "in effect" after it has been adopted by the Director of the CDC. A recommendation is considered to be for routine use after it appears on the Immunization Schedules of the CDC.
• Evidence-informed preventive care and screenings for infants, children, and adolescents as provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA). The current HRSA supported guidelines appear in two charts: the Periodicity Schedule of the Bright Futures Recommendations for Pediatric Health Care, and the Uniform Panel of the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children.
• With respect to women, evidence-informed preventive care and screening, as provided for in the comprehensive guidelines supported by the HRSA (not otherwise addressed by the USPSTF recommendations). The Department of HHS is developing these guidelines and expects to issue them no later than August 1, 2011.

It's important to note that the law does not prohibit a plan or issuer from providing coverage for services in addition to those recommended by the USPSTF or from denying coverage for services that are not recommended by the USPSTF. Plans and issuers are not required to provide coverage for recommended preventive services delivered by out-of-network providers.

The law requires coverage of the services listed in the recommendations of the USPSTF, ACIP and HRSA, as specified above. The complete list of current recommendations that are required to be covered under PPACA and the Interim Final Rules (IFR) was published in the Federal Register on July 19.

This list will be updated by HHS on an on-going basis and should be consulted for the current list. For breast cancer screening, mammography, and prevention, the IFR provides that the recommendations issued by the USPSTF in 2002 are to be considered the most current (until they are updated), rather than those issued in or around November 2009.

UnitedHealthcare will offer these Preventive Benefit Services to meet or exceed the federal regulations with no cost sharing (100% coverage).

If you visit a doctor for a Preventive care visit and as a result a prescription is written, is the visit considered Preventive care or is the visit charged as an office visit with a copay? Has the government specified how this process will change and the claim will be adjudicated as Preventive coverage?

The fact that a physician writes a prescription does not affect whether the visit, or more to the point, services rendered during the visit, are preventive. Any prescription written will be covered according to the client's prescription drug plan, unless the Secretary of Health and Human Services implements further regulations regarding prescriptions.

The IFR provides that coverage for recommended preventive services must be provided for plan years (in the individual market, policy years) beginning on or after the later of September 23, 2010, or one year after the date the recommendation or guideline is issued. Thus, recommendations and guidelines issued prior to September 23, 2009 must be provided for plan years (in the individual market, policy years) beginning on or after September 23, 2010. For example, the comprehensive guidelines set forth in the Periodicity Schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care went into effect before September 23, 2009. Accordingly, plans and issuers are required to provide coverage without cost sharing for these services in the first plan year (in the individual market, the policy year) that begins on or after September, 23, 2010.

The comprehensive guidelines that are illustrated in the Uniform Panel of the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children went in effect May 21, 2010. Plans and issuers are required to provide coverage without cost sharing for these services in the first plan year (in the individual market, policy year) that begins on or after May 21, 2011.

A recommendation or guideline of the USPSTF is considered to be issued on the last day of the month on which the USPSTF publishes or otherwise releases the recommendation. A recommendation or guideline of the ACIP is considered to be issued on the date on which it is adopted by the Director of the CDC. Finally, 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.

Any change to a recommendation or guideline that has – at any point since September 23, 2009 – been included in the recommended preventive services will be noted.

Yes, group health plans and issuers are prohibited from imposing cost-sharing requirements for the recommended preventive services when those services are provided by in-network providers. Plans and issuers are not required to cover preventive services provided by out-of-network providers. If such services are covered, a plan or issuer may impose cost-sharing requirements for recommended services delivered by out-of-network providers.

Prohibited cost-sharing mechanisms include, but are not limited to, copayments, coinsurance and deductibles.

No. The prohibition on cost sharing applies only to recommended preventive services furnished by in-network providers. Plans and issuers are not required to cover preventive services provided by out-of-network providers and may impose cost-sharing requirements for covered recommended services delivered by out-of-network providers.

No, the prohibition on cost sharing only applies to the recommended preventive services required to be covered. Under PPACA a plan or issuer may provide coverage for services in addition to the recommended preventive services. For such additional preventive services, a plan or issuer may impose cost-sharing requirements at its discretion. The IFR also clarifies that a plan or issuer may impose cost sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive health service.

The IFR provides clarification of when cost sharing may be applied in connection with preventive care provided during an office visit. Cost sharing with respect to an office visit is prohibited if the primary purpose of the office visit is the recommended preventive service and the recommended preventive service is NOT billed separately (or tracked separately as individual encounter data). Cost sharing with respect to the office visit is permitted if the recommended preventive service is billed separately from the office visit (or is tracked separately as individual encounter data). Although cost sharing with respect to the office visit is permitted, cost sharing with respect to the separately billed/tracked recommended preventive service is not permitted. Cost sharing with respect to the office visit is also permitted if the recommended preventive service is not billed separately (or is not tracked as individual encounter data separately) from an office visit but the primary purpose of the office visit is not the delivery of such an item or service.

Co-payments and other cost sharing requirements are permitted for preventive services received by a member from an out-of-network provider. Note, grandfathered plans (that is, generally, those in existence when the law was passed on March 23, 2010) are not subject to the preventive coverage requirement prohibiting cost sharing on preventive health services.

The regulations define "cost sharing" broadly, so that a plan or issuer may not impose a dollar maximum on preventive care services. A plan or issuer may, however, use reasonable medical management techniques to determine the frequency, method, treatment or setting for a required preventive service to the extent that such factors are not specified in the recommendation or guideline that applies to the preventive service.

Note, also, that for plan and policy years beginning on or after September 23, 2010, PPACA prohibits plans and issuers (including grandfathered plans) from imposing lifetime dollar limits on essential health benefits. Preventive services that are required to be provided without cost sharing are essential health benefits. Thus, such services cannot be subject to a lifetime dollar limit.

Annual dollar limits on essential benefits are also prohibited (including in the case of grandfathered plans) for plan and policy years beginning on or after January 1, 2014. For years before that date, restricted annual limits on essential benefits may be imposed as follows:

• For plan or policy years beginning on or after September 23, 2010 but before September 23, 2011, 750,000;
• For plan or policy years beginning on or after September 23, 2011 but before September 23, 2012, $1.25 million; and
• For plan or policy years beginning on or after September 23, 2012 but before January 1, 2014, $2 million.