Health and Human Services Releases Final Interim Guidance – Preventative Health Services

July 26th, 2010 by HDHPexpert                                                                              Print

On July 14, the Departments of Treasury, Labor, and Health and Human Services jointly released Interim Final Rules (IFRs) for group health plans and health insurance issuers related to coverage of preventive services under the Patient Protection and Affordable Care Act (PPACA).

Under the regulations, plans must cover without copay, coinsurance or deductible – certain preventive services that have “strong scientific evidence of their health benefits.” (Safe Harbor Benefits)

These are interim final rules (IFRs), which means final rules may eventually differ, but these rules are final in the interim. As additional clarification is made available whether through rule-making or otherwise, we’ll share that information with you.

General highlights of new regulations:

• Grandfathered plans are exempt for as long as they remain grandfathered.
• Non-grandfathered plans (i.e., plans either not in effect on 3/23/10 or that made changes since then resulting in loss of grandfathered status) must comply with the no-cost-sharing requirement beginning with the first plan year on or after September 23, 2010.
• Preventive services are to be covered without any cost-sharing requirement when delivered by a network provider.
• Employers and insurers are not required to provide coverage for recommended preventive services delivered by an out-of-network provider or may impose cost-sharing for recommended preventive services delivered by an out-of-network health care provider.
• If a guideline for a recommended preventive service does not specify the frequency, method, treatment, or setting for the service, the plan or issuer may use “reasonable medical management techniques” to determine any coverage limitations on the service.

General list of services to be offered without copay, coinsurance or deductible:

Evidence-based preventive services: This list of items is taken from the current recommendations of the United States Preventive Services. They are included only if they have a rating of A or B. This broad list generally includes:

• Breast cancer and cervical cancer screenings
• Colon cancer screenings
• Screening for vitamin deficiencies during pregnancy
• Screenings for diabetes, high cholesterol and high blood pressure

Routine vaccinations: A list of immunizations – recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention – are included in the rule. They are considered routine for use with children, adolescents, and adults and range from childhood immunizations to periodic tetanus shots for adults.

Prevention for children: The rule includes preventive care guidelines for children – from birth to age 21 – developed by the Health Resources and Services Administration with the American Academy of Pediatrics. Services include regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity.

Prevention for women: The regulation mandates certain preventive care measures for women. These recommendations will be in place until new requirements for prevention for women are issued by the United States Preventive Services Task Force or appear in comprehensive guidelines supported by the Health Resources and Services Administration.

Full list of covered preventive services issued as part of the Interim Final Regulations:http://www.healthcare.gov/center/regulations/prevention/taskforce.html

Billing and Office Visits

If a recommended preventive item or service is billed separately from an office visit, then cost-sharing may be applied to the office visit

If a recommended preventive item or service is not billed separately from an office visit and the primary purpose of the office visit is the delivery of such item or service, then cost-sharing requirements may not be imposed with respect to the office visit.

If a recommended preventive item or service is not billed separately from an office visit and the primary purpose of the office visit is not the delivery of the preventive item or service, them cost-sharing made be applied to the office visit.

Source

What Are Safe Harbor Benefits? – List and Explanation

July 20th, 2010 by HDHPexpert                                                                              Print

The term “Safe Harbor Benefits” refers to preventative treatments that are covered in full from day one as an added benefit of most high-deductible health plans (HDHPs).  A deductible does not need to be reached before Safe Harbor Benefits begin being covered in-full.

The insurance carriers want to encourage those insured to regularly obtain preventative care.  In theory, covering simple visits in-full (no out-of-pocket cost once insurance pays the provider) such as physicals and gynecological routine exams will lower systemwide medical costs because they will catch serious potential medical concerns early.

The list below outlines Safe Harbor Benefits that are covered by most HDHPs.  For the most part they are covered in-full once per 12 months, although some plans do cover certain visits in-full every 6 months.  Check with your provider for the most up-to-date information on Safe Harbor Benefits.

Covered in-full with most HDHP’s / HSA-compatibles:

• Adult physicals
• Well child visits
• Mammograms
• Prostate-specific antigen (PSA) tests
• Colonoscopies / sigmoidoscopies
• OB/GYN routine exams.

Please keep in mind these may vary by plan, state, provider, etc.

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