What is Required Under the New Preventive Health Guidelines?

These new guidelines have prompted plans to ask questions about exactly what is required under the preventive care rules and when.

What preventive care coverage does PPACA require?

PPACA requires nongrandfathered group health plans to cover the following recommended services:

• Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force (USPSTF);
• 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 (CDC);
• With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by Health Resources and Services Administration (HRSA), which is a part of HHS; and
• With respect to women, such additional preventive care and screenings as provided for in comprehensive guidelines supported by the HRSA (these are the new, recently adopted guidelines).

Plans are required to cover these services free of charge, without cost sharing (for example, without imposing copayments or coinsurance). 

More detail on these recommendations can be found at http://www.healthcare.gov/center/regulations/prevention/taskforce.html.  

When do these requirements apply?

The requirement to cover these preventive care services applies to plan years beginning on or after September 23, 2010 (January 1, 2011 for calendar year plans).  These requirements do not apply to grandfathered plans.

What do the new, recently adopted guidelines require?

On August 1, 2011, the Secretary of HHS announced new guidelines for women's preventive services (as recommended by the Institutes of Medicine).  See www.hrsa.gov/womensguidelines /.  The new guidelines require coverage in the following categories:

• Well-woman visits;
• Screening for gestational diabetes;
• HPV testing;
• Counseling for STD infections;
• Counseling and screening fro HIV;
• Contraceptive methods and counseling (with an exemption for certain religious employers);
• Breastfeeding support, supplies, and counseling; and
• Screening and counseling for interpersonal and domestic violence. 

When must plans incorporate the recently adopted guidelines into coverage?

The original preventive care regulation provided, for any new recommendations or guidelines that are adopted, a plan must provide coverage for plan years beginning on or after the date that is one year after the applicable recommendation or guideline is issued.   

Since the new women's preventive care guidelines were adopted August 1, 2011, health plans (other than grandfathered plans), must start offering this coverage for plan years that begin on or after August 1, 2012 (January 1, 2013 for calendar year plans). 

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You can find a handy list of Key Provisions of the Patient Protection and Affordable Care Act and their effective dates at http://www.groom.com/HCR-Chart.html   

Contributors:

Christy Tinnes is a Principal in the Health & Welfare Group of Groom Law Group in Washington, D.C.  She is involved in all aspects of health and welfare plans, including ERISA, HIPAA portability, HIPAA privacy, COBRA, and Medicare.  She represents employers designing health plans as well as insurers designing new products.  Most recently, she has been extensively involved in the insurance market reform and employer mandate provisions of the health-care reform legislation.

Brigen Winters is a Principal at Groom Law Group, Chartered, where he co-chairs the firm's Policy and Legislation group. He counsels plan sponsors, insurers, and other financial institutions regarding health and welfare, executive compensation, and tax-qualified arrangements, and advises clients on legislative and regulatory matters, with a particular focus on the recently enacted health-reform legislation.

PLEASE NOTE:  This feature is intended to provide general information only, does not constitute legal advice, and cannot be used or substituted for legal or tax advice.