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HCR Update: Preventive Care Provision

Aug 09, 2010

Health Care Reform Update

August 6, 2010


Interim final rules contain details about the preventive care provision 

As you may know, the health care reform law includes a provision requiring health insurers to cover preventive services with no member cost sharing. Recently-published interim final regulations clarify this provision. Non-grandfathered plans issued or renewed on or after September 23, 2010, will not include member cost sharing or copays for the following preventive care provided in-network: 

£     Evidence-based items or services that have a rating of A or B in the current recommendations of the United States Preventive Services Task Force.

£     Immunizations for routine use in children, adolescents, and adults that are recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.

£     For infants, children and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

£     For women, to the extent not otherwise addressed by the United States Preventive Services Task Force recommendations, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration.  

Other key points:

£     This impacts non-grandfathered plans issued or renewed on or after September 23, 2010.

£     This applies to in-network services. Out-of-network services will have the same cost-sharing requirements as they do today.

£     Most of the recommended screenings, immunizations and exam services are already on our preventive services list. We are adding the new, required preventive services to this existing list. 

£     An example of a new preventive service is counseling related to aspirin use, tobacco cessation, obesity and alcohol use.

£     Some services currently covered as medical/maternity will now be considered preventive services. This includes several recommended screenings for pregnant women.  

As with the other provisions in the health care reform law, we're committed to implementing this provision in a manner that helps members have access to quality health care services. If you have any questions, talk with your sales representative.


New guidance issued on outpatient mental health/substance abuse benefits 

On February 2, 2010, the federal government issued regulations that interpret the changes to the federal Mental Health Parity Act, which requires "parity" between the financial requirements and treatment limitations applied to medical or surgical benefits, and mental health and substance use disorder benefits. This law impacts group health plans, both fully insured and self-funded, with more than 50 total employees.  

On July 1, 2010, the federal government issued additional "safe harbor" guidance indicating that until it issues final regulations, federal agencies will establish an enforcement safe harbor under which they will not take enforcement action against a plan or issuer that divides its benefits for outpatient services into two sub-classifications for applying the financial requirement and treatment limitation rules under mental health parity law:office visits and  all other outpatient items and services. 

After the sub-classifications are established, the plan or issuer may not impose any financial requirement or treatment limitation on mental health or substance use disorder benefits in any sub-classification (that is, office visits or non-office visits) that is more restrictive than the predominant financial requirement or treatment limitation that applies to substantially all medical/surgical benefits in the sub-classification using the methodology set forth in the interim final rules issued February 2.  

This safe harbor guidance recognizes that it is common for benefit plans to apply a copayment for office visits (for example, physician or psychologist visits) but coinsurance for other outpatient services (for example, outpatient surgery, facility charges for day treatment centers, laboratory charges or other medical items), and, thus, provides an alternate method for evaluating outpatient services by testing office visits and all other outpatient services separately. Our company will use this alternate method for the majority of new sales and renewals beginning with October effective dates.   

For more information about the Mental Health Parity Act, please refer to this summary and frequently asked questions.  

If you have any questions, talk with your sales representative.

Health care reform webinar recordings now available 

Did you miss the premiere of the health care reform webinars, which attracted about 4,700 brokers and 4,000 employers last week? Or do you just want to recharge your memory banks with the information presented that day? Then you're in luck. You can access recordings of both the broker and employer webinars at . We'll also be e-mailing these links to our group customers.

Getting to the bottom of your health care costs   

Did you know:  Specialty drugs contribute to high and rising health care costs?


According to the Kaiser Family Foundation and Sonderegger Research Center, specialty drugs - drugs that are usually used for unique reasons - can save and extend lives, but they're much more expensive than other drugs.  For example, a new cancer drug can cost $100,000 or more per patient for the course of the treatment.

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