PPACA Regulatory Update
July, 14, 2010

As reported by SIIA’s Government Relations Staff, Federal agencies will be continually issuing regulations and notices of guidance pertaining to how provisions of the newly enacted Patient Protection and Affordable Care Act will be implemented. SIIA’s Government Relations Staff will develop concise summaries and distribute to membership immediately thereafter.

Departments of Labor, Treasury and Health and Human Services Jointly Release Interim Final Rule on Coverage of Preventative Services

The Departments of Labor, Treasury and Health and Human Services this afternoon jointly released an interim final rule on requirements to cover preventative services.

Background on Requirement to Cover Preventative Services:

The PPACA requires non-grandfathered health plans (including non-grandfathered self-insured) to cover mandated preventative services with no cost-sharing requirement.

Final Interim Rule on Coverage of Preventative Services:

Plans will be required to provide first-dollar coverage for the following 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 (Task Force) 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 of the Centers for Disease Control and Prevention (Advisory Committee) with respect to the individual involved. A recommendation of the Advisory Committee is considered to be “in effect” after it has been adopted by the Director of the Centers for Disease Control and Prevention. A recommendation is considered to be for routine use if it appears on the Immunization Schedules of the Centers for Disease Control and Prevention.
  • With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA).
  • With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA (not otherwise addressed by the recommendations of the Task Force). The Department of HHS is developing these guidelines and expects to issue them no later than August 1, 2011.

If preventative services are performed during a regular office visit, the plan may require cost-sharing for the visit if the preventative service is billed separately. In turn, if the primary reason for the office visit was to receive the preventative service and that service was not billed separately from the office visit, the plan is prohibited from requiring any cost-sharing.

Under these rules, plans are permitted to require cost-sharing for preventative services if they are performed by an out-of-network provider.

Plans are permitted to make coverage limitations using “reasonable medical techniques” if recommendations by a provider for preventative services does not specify the frequency, method, treatment or setting for the provision of that service.

Plans may cover additional preventative services than those mandated by this rule and plans may require cost-sharing requirements at its discretion.

Plans are required to provide first-dollar coverage for all preventative services that were recommended prior to 9/23/09. Plans will have at least one year to implement any further recommendations and guidelines relating to preventative services that agencies have imposed since 9/23/10 or may impose in the future.

Plans are permitted to require cost-sharing for any service that was once recommended, but is no longer.

Stay Informed on the PPACA

SIIA’s Government Relations Staff is continually updating SIIA’s PPACA In-Depth Analysis as regulations and guidance are issued by Federal agencies and Congress. Please continue to visit our website to review the most up-to-date information - http://www.siia.org/i4a/pages/index.cfm?pageID=5401.