Health Care Reform — Preventive Services Become More Accessible with No Cost-Sharing
Employees in employer-sponsored plans and others who may have put off preventive health care screenings due to cost may soon benefit from Health Care Reform, as many preventive health care items and services will no longer require cost-sharing. For plan years beginning on or after September 23, 2010, non-grandfathered group health plans, including both fully insured and self-insured plans, must cover in-network preventive services.
The preventive services1 must be treatments or screenings recommended by the United States Preventive Services Task Force (USPSTF)2 at least one year prior to the date that the treatment is rendered and generally fall under one of four categories:
- Preventive screening and services for adults in each of five categories:
- Pregnancy-related care
- Children's preventive services
- Screening services
- Health promotion education counseling services
- Immunizations
- Evidence-based services with a rating of A or B in the current recommendations of the USPSTF. Examples are:
- Colon and cervical cancer screenings
- Annual mammogram breast cancer screenings
- Vitamin deficiencies screening during pregnancy
- Diabetes screening
- High cholesterol screening
- High blood pressure screening
- Tobacco cessation counseling
- Routine immunizations such as:
- Tetanus shots for adults
- Routine childhood immunizations
- Preventive care and screenings for infants, children, and adolescents including:
- Regular pediatrician visits
- Vision and hearing screenings
- Developmental assessments
- Obesity screening and counseling
1 These examples are not all inclusive. For a complete list, and the effective date, go to www.healthcare.gov/center/regulations/prevention/taskforce.html. If new preventive services are made by USPSTF, they will become effective one year after the issuance of the guideline.
2 The USPSTF is the leading independent panel of private-sector experts in prevention and primary care. Its recommendations are considered the "gold standard" for clinical preventive services.
The requirement to provide preventive services at no cost is for services recommended by USPSTF at least one year prior to the date that the treatment is rendered. For example, screening for obesity in children was recommended by the Task Force on January 31, 2010; therefore, obesity screening will become part of the preventive services provided with no cost-sharing for plan years beginning on or after January 31, 2011. Any screening prior to that date would be subject to any standard co-pay, co-insurance or deductible.
When an accepted preventive service is provided during an office visit, the billing may be handled differently depending upon the circumstance:
- A cost-sharing requirement may be imposed for an office visit when the primary purpose of the visit was for a recommended preventive service and it is billed separately from an office visit.
- A cost-sharing requirement may not be imposed for an office visit if the primary purpose of the visit was for a recommended preventive service and it is not billed separately from an office visit.
- A cost-sharing requirement may be imposed on an office visit, regardless of whether recommended services are billed separately from an office visit, if the primary purpose of the office visit was not to provide a recommended preventive service or item. In addition, a plan could exclude coverage for the office visit entirely to the extent otherwise permitted under applicable law.
As a result of this requirement, health plans must expand the definition of what is covered under "preventive health services," and may issue premium rate adjustments based on the additional benefits that will now be covered in full.
No action is required by employers with regard to this requirement. Upon renewal, carriers should automatically update your contract to bring you into compliance.
For plans that begin on or after September 23, 2010, many preventive items and services will become more accessible as they will no longer require cost-sharing. However, nothing will prevent a plan or issuer from using reasonable medical management techniques to determine the frequency, method, treatment, or setting for an item or service to the extent that it is not specified in the recommendation or guideline.
Notifying employees of the preventive services available with no cost-sharing can increase participation in your employer-sponsored plan and increase employee loyalty and satisfaction.
For more specific information regarding your plan's preventive services and cost-sharing, please contact your insurance carrier.
Paychex Insurance Agency Can Help
Paychex Insurance Agency is a full service insurance agency that has taken a leadership role in transforming how businesses like yours adapt to and benefit from the rapidly changing insurance industry. We're ready to offer information and assistance to help you navigate the recent Health Care Reform initiatives.
We can help:
- Educate you on the new requirements during health plan renewal.
- Provide resources to help you explain the changes to your employees.
- Follow the latest regulations to keep you informed about any legislative changes that affect you and your business.
Health Care Reform Updates
With access to legislative and regulatory specialists in Washington, D.C. and expert, in-house sources of legal and compliance guidance, Paychex Insurance Agency is your source for Health Care Reform knowledge, tools, and resources.
Whether you're looking for a Business Owner Policy, Workers' Compensation insurance or group health and life insurance, Paychex Insurance Agency offers flexible, scalable insurance solutions for you, your business and your employees. To learn more about how we can meet your insurance needs, call 877-393-8868 or have an agent call you.
The Department of Health and Human Services and the Internal Revenue Service (IRS) continue to provide specifics and guidance on the Health Care Reform Act. Paychex will monitor these regulatory developments and provide updates as appropriate.
The information in these materials should not be considered legal or accounting advice, and it should not substitute for legal, accounting, and other professional advice where the facts and circumstances warrant. It is provided for informational purposes only. If you require legal or accounting advice, or need other professional assistance, you should always consult your licensed attorney, accountant, or other federally licensed tax professional to discuss your particular facts, circumstances, and business needs.
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