On July 14, 2010, the U.S. Treasury Department, Internal Revenue Service, the Department of Labor’s Employee Benefits Security Administration and the U.S. Department of Health and Human Services issued interim final rules to implement the provisions of the new Patient Protection and Affordable Care Act (“PPACA”) requiring non-grandfathered group health plans and health insurance issuers in the group and individual markets to provide coverage for preventive health services listed in certain recommendations and guidelines without imposing any cost-sharing requirements on covered individuals. The prohibition on cost-sharing includes copayments, coinsurance or deductibles.
These requirements apply to the following “recommended preventive services”:
The regulations provide guidance related to when a plan or issuer may impose cost-sharing requirements when a recommended preventive service is delivered during an office visit.
The regulations clarify that a plan or health insurance coverage that has a network of providers is not required to provide coverage or may provide coverage and impose cost-sharing for recommended preventive services delivered by an out-of-network provider. In addition, cost-sharing requirements may continue to be applied by plans and issuers to preventive services that are not on the list of recommended preventive services if permitted under applicable state law.
The new requirements for coverage of recommended preventive services apply to non-grandfathered group health plans and health insurers for plan years and policy years beginning on or after Sept. 23, 2010. Coverage for specific recommended preventive services must be provided for plan years or policy years beginning on or after the later of September 23, 2010, or one year after the date the recommendation or guideline is issued. See the current list of recommended preventive services.
All non-grandfathered group health plans will need to be reviewed prior to the applicable effective date to determine if the current coverage complies with the new preventive services requirements and amendments will need to be made, as necessary, to conform to these requirements. Future compliance with the preventive services requirements will need to be monitored on a periodic basis as the specific recommended preventive services are subject to change.
These requirements are some of the many changes made by PPACA and by the Health Care Reconciliation Act (which was signed into law as a companion to PPACA).
Please contact Ruth Ann Maloney ( or 216.861.7566) or any member of our Health Care Reform team if you have any questions about this information or how the regulations will impact your employee benefit plans.
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