• Scope of recommended preventive services: The regulations finalize the requirement to provide coverage without cost sharing with respect to the following three categories of recommendations and guidelines (in addition to those provided for in the Health Resources and Services Administration (HRSA) guidelines for women):
◦ Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the U.S. Preventive Services Task Force
◦ Immunizations for routine use that have in effect a recommendation from the CDC’s Advisory Committee on Immunization Practices
◦ Evidence-informed preventive care and screenings for infants, children and adolescents, provided for in guidelines supported by HRSA
• Office visits: The final regulations clarify that, when a recommended preventive service is not billed separately (or is not tracked as individual encounter data separately) from an office visit, plans and issuers must look to the primary purpose of the office visit when determining whether they may impose cost sharing with respect to the office visit. The Departments anticipate that the determination of the primary purpose of the visit will be resolved through normal billing and coding activities, as they are for other services.
• Out-of-network providers: The final regulations do not require plans or issuers to provide coverage for recommended preventive services delivered by an out-of- network provider. However, the regulations clarify that a plan or issuer that does not have a provider in its network who can provide a particular recommended preventive service is required to cover the preventive service when performed by an out-of-network provider, and the plan or issuer may not impose cost sharing with respect to the preventive service.
• Reasonable medical management: Plans and issuers may use reasonable medical management techniques to determine the frequency, method, treatment or setting for required preventive coverage items or services to the extent they are not specified in the relevant recommendation or guideline. A plan or issuer may rely on the relevant clinical evidence base and established reasonable medical management techniques to determine the frequency, method, treatment or setting for coverage of a recommended preventive health service.
• Services not described: The final regulations clarify that a plan or issuer may cover preventive services in addition to those required to be covered under the ACA. For these additional preventive services, a plan or issuer may impose cost sharing at its discretion, consistent with applicable law. A plan or issuer may also impose cost sharing for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.
• Timing: The preventive coverage requirement took effect for plan years beginning on or after Sept. 23, 2010. Coverage pursuant to recommendations or guidelines issued after that date must be provided for plan years beginning one year after the date the recommendation or guideline is issued.
Also, required coverage must be provided through the end of the plan year, even if the recommendation or guideline changes during the plan year. This rule does not apply if a recommendation or guideline is downgraded to a “D” rating or if any related item or service is subject to a safety recall or is otherwise determined to pose a significant safety concern by an authorized federal agency.
On July 10, 2015, the Departments of Labor (DOL), Health and Human Services (HHS) and the Treasury (Departments) released final regulations on the ACA’s women’s preventive care coverage requirement.
• Finalize an accommodation for eligible nonprofit organizations and for- profit businesses with religious objections to providing contraceptive coverage, including related documentation standards.
• Clarify general rules on the coverage of preventive services generally.
The regulations are applicable on the first day of the first plan or policy year beginning on or after Sept. 12, 2015.