Group health plans and health insurance issuers offering group or individual health insurance coverage must provide benefits for and prohibit the imposition of cost-sharing requirements for:
- Evidence-based items or services that have in effect a rating of A or B in the current recommendations of the United States Preventive Services Task Force with respect to the individual involved. Services with a rating of A or B include screening and counseling to reduce alcohol misuse; aspirin therapy for certain men age 45-79 years and women age 55 to 79 years; assorted pregnancy-care screenings; and screening for depression, cholesterol abnormalities, anemia, hypothyroidism, obesity, colorectal cancer, tobacco use, and visual acuity in children.
- Immunizations for routine use, as provided on the Immunization Schedules of the Centers for Disease Control and Prevention, that have "in effect" a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention (CDC). A recommendation is "in effect" if it has been adopted by the Director of the CDC.
- Certain preventive care and screenings for infants, children and adolescents, as set forth in guidelines supported by the Health Resources and Services Administration (HRSA).
- Other preventive care and screenings for women in guidelines supported by the HRSA.
Cost-sharing requirements. Note that if a recommended preventive service (RPS) is billed separately from an office visit, then cost-sharing requirements for the office visit may be imposed. If an RPS is not billed separately and the primary purpose of the visit is the delivery of a preventive item or service, then cost-sharing requirements may not be imposed. If an RPS is not billed separately but the primary purpose of the office visit is not the delivery of a preventive item or service, then cost-sharing requirements may be imposed.
Source: 75 FR 41726, July 19, 2010.