
Health Care Reform – Recommended Preventive Care Services
To make preventive care more accessible and affordable, the Patient Protection and Affordable Care Act (PPACA) requires health plans and issuers to cover certain preventive care services without imposing any cost-sharing. Essentially, PPACA’s preventive care mandate requires health plans and issuers to provide coverage for recommended preventive care services without charging deductibles, copayments or coinsurance when services are provided by an in-network provider. PPACA’s preventive care mandate became effective for plan years beginning on or after Sept. 23, 2010. It does not apply to grandfathered plans.
The Departments of Health and Human Services, Labor and Treasury issued interim final guidance in July 2010 describing the recommended preventive care services that must be covered without any cost-sharing. The recommended preventive care services are based on guidelines developed by other governmental agencies, such as the United States Preventive Services Task Force (USPSTF). Most of the recommended preventive care services are currently effective for health plans and issuers. However, there are a handful of recommended preventive care services that become effective in future years.
This Benefit Logic Legislative Brief summarizes the recommended preventive care services that non-grandfathered health plans and issuers must cover without imposing cost-sharing, and specifically highlights recommended preventive care services that become effective in future years.
basic guidelines
The preventive care services that must be covered by non-grandfathered health plans and issuers without cost-sharing are:
- Evidence-based items or services that have an A or B rating in the current recommendations of the USPSTF;
- Immunizations for routine use in children, adolescents and adults that are currently recommended by the Centers for Disease Control and Prevention (CDC) and included on the CDC’s immunization schedules;
- For infants, children and adolescents, evidence-informed preventive care and screenings provided for in the Health Resources and Services Administration (HRSA) guidelines; and
- For women, evidence-informed preventive care and screenings provided in guidelines supported by HRSA.
The complete list of recommended preventive care services under each category is available at: www.healthcare.gov/law/resources/regulations/prevention/recommendations.html.
Updates to recommended preventive Care services
Most of the recommended preventive care services became effective for the plan year beginning on or after Sept. 23, 2010 (that is, Jan. 1, 2011, for calendar year plans). However, the preventive care services recommendations are updated from time to time. To allow for transition time, health plans and issuers generally have at least one year from the time a new service is added to the list of recommended preventive care services to comply with the new requirement. The following preventive care services were added to the list after Sept. 23, 2009, and were not in effect for plan years beginning on Sept. 23, 2010. Depending on when the plan year starts, some of these preventive care services may already be in effect for a plan or issuer, while others will become effective in the future.
- Meningococcal vaccine (added Sept. 25, 2009) – Effective for plan years beginning on or after Sept. 25, 2010. The new recommendation only differs with respect to revaccination of individuals at increased risk by extending coverage to certain individuals who had previously received the meningococcal conjugate vaccine.
- HPV vaccine (added Jan. 8, 2010) – Effective for plan years beginning on or after Jan. 8, 2011. The new recommendation addresses vaccination with the bivalent (as opposed to quadrivalent) HPV vaccine and vaccination of males.
- Obesity screening and counseling for children (added Jan. 31, 2010) – Effective for plan years beginning on or after Jan. 31, 2011.
- Influenza vaccine for all adults 19 to 49 years of age (added March 2, 2010) – Effective for plan years beginning on or after March 2, 2011;
- Pneumococcal vaccine (added March 12, 2010) – Effective for plan years beginning on or after March 12, 2011. This is an expanded recommendation on pneumococcal vaccine.
- MMR/varicella vaccine (added May 7, 2010) – Effective for plan years beginning on or after May 7, 2011. This is a new recommendation related to combination measles, mumps, rubella and varicella vaccine.
- Heritable disorders in newborns and children (added May 21, 2010) – Effective for plan years beginning on or after May 21, 2011; and
- Women’s preventive health services (added Aug. 1, 2011) – Effective for plan years beginning on or after Aug. 1, 2012. The new recommendation includes well-woman visits, gestational diabetes screening, HPV DNA testing for women age 30 and older, sexually transmitted infection counseling, HIV screening and counseling, FDA-approved contraception methods and contraceptive counseling, breastfeeding support, supplies and counseling and domestic violence screening and counseling.
It is likely that the list of recommended preventive care services will continue to grow. Health plans should work with their advisors to monitor additions to the list of recommended preventive care services and to track the effective date for each new preventive care service.
Benefit Logic will continue to monitor health care reform developments and will provide updated information as it becomes available.
This Benefit Logic Legislative Brief is not intended to be exhaustive nor should any discussion or opinions be construed as legal advice. Readers should contact legal counsel for legal advice.

© 2011 Zywave, Inc. All rights reserved. EEM 11/11


Source: The Centers for Disease Control and Prevention
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