Preventive Care

For plan years beginning on or after September 23, 2010, non-grandfathered health plans cannot require cost sharing (such as copayments or deductibles) for preventive care services that are specified by the Federal government, including immunizations. The list of specified preventive care services is expected to be updated periodically and plans must comply for plan years beginning on or after one year after the new recommendation or guideline is published.

Note: The requirement to cover preventive care only applies to certain types of health plans, such as major medical insurance. It does not apply to HIPAA excepted benefits, such as disability, cancer, hospital indemnity, or accident insurance. Click here for more information about the types of benefits that are exempt from the ACA plan design mandates.

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Does the plan have to cover these preventive care services if delivered by out-of-network providers?

No. Plans that offer out-of-network benefits are not required to cover these preventive services if delivered by out-of-network providers. Alternatively, the employer may choose to impose cost sharing if the service is delivered by an out-of-network provider.

If an issue is discovered during a preventive screening, does the treatment have to be provided without cost sharing?

No. The plan may impose cost sharing requirements on treatment services, even those that are delivered as part of an appointment that was initially scheduled for a preventive service.

If the preventive service is provided during an office visit, may a copayment be charged for the visit?

It depends. The interim final regulations clarify when cost sharing may be imposed in connection with a preventive service provided during an office visit.

If a preventive service is billed separately from the office visit, the plan may impose cost sharing for the office visit.
If the preventive service is not billed separately from an office visit and the primary purpose of the office visit is the delivery of the preventive service, then the plan may not impose cost sharing for the office visit.
If the preventive service is not billed separately from an office visit and the primary purpose of the office visit is not the delivery of the preventive service, the plan may impose cost sharing for the office visit.

The regulations include a number of examples illustrating these rules.

Neither American Fidelity Assurance Company nor American Fidelity Administrative Services provides tax or legal advice and, given the complexity of these laws, we always recommend working with your legal counsel on how the laws impact your specific situation.

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Hot Topics

Does the plan have to cover these preventive care services if delivered by out-of-­network providers?

If an issue is discovered during a preventive screening, does the treatment have to be provided without cost sharing?

If the preventive service is provided during an office visit, may a copayment be charged for the visit?

Does the plan have to cover these preventive care services if delivered by out-of-network providers?