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CCH® BENEFITS — 07/20/10

Rules Clarify Office Visit Reimbursements For Preventive Care Services

from Spencer’s Benefits Reports: Cost-sharing requirements may be imposed on preventive care services if the services are provided during an office visit whose primary purpose is not preventive care and if the services are not billed separately, according to new interim final rules issued jointly by the Internal Revenue Service, the Department of Labor’s Employee Benefits Security Administration (EBSA), and the Department of Health and Human Services’ Office of Consumer Information and Insurance Oversight (OCIIO).

The rules implement the preventive care requirements in Public Health Service Act Sec. 2713, as added by the Patient Protection and Affordable Care Act (P.L. 111-148). The rules are scheduled to be published in the July 19 Federal Register.

PHSA Sec. 2713 requires group health plans to cover, with no cost sharing, the following:

• certain evidence-based items (with A or B ratings) in the recommendations of the United States Preventive Services Task Force;
• immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention;
• evidence-based preventive care and screenings for infants, children, and adolescents provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and
• additional women’s preventive care and screenings “in comprehensive guidelines supported by the HRSA.”

The complete list of recommendations and guidelines that are required to be covered under these interim final regulations can be found at http://www.HealthCare.gov/center/regulations/prevention.html.

Office Visit Clarification

The interim final regulations clarify how the preventive care cost-sharing requirements work during an office visit. First, if a recommended preventive service is billed separately from an office visit, then a plan may impose cost-sharing requirements for the office visit (but not for the preventive care services).

Second, if a recommended preventive service is not billed separately from an office visit and the primary purpose of the office visit is the delivery of a preventive service, then a plan may not impose cost-sharing requirements with respect to the office visit.

Finally, if a recommended preventive service is not billed separately from an office visit and the primary purpose of the office visit is not the delivery of a preventive service, then a plan may impose cost-sharing requirements for the office visit.

Additional Guidance

The interim final rules also provide for the following:

With respect to a plan that has a network of providers, the regulations make clear that a plan is not required to provide coverage for recommended preventive services delivered by an out-of-network provider.

The regulations clarify that a plan continues to have the option to cover preventive services in addition to those required to be covered by PHSA Sec.2713. For such additional preventive services, a plan may impose cost sharing requirements at its discretion. Moreover, a plan may impose cost-sharing requirements for a treatment that is not a recommended preventive service, even if the treatment results from a recommended preventive service.

Finally, these interim final regulations make clear that a plan is not required to provide coverage or waive cost-sharing requirements for any item or service that has ceased to be a recommended preventive service.

The interim final regulations are effective 60 days after publication in the Federal Register. However, the rules generally apply to group health plans and group health insurance issuers for plan years beginning on or after Sept. 23, 2010.

NOTE: If final rules are not issued within three years, the IRS version of these interim regulations expires (IRC Sec. 7805(e)). The DOL and OCIIO versions have no expiration date.

Comments on the interim rules, which must be received within 60 days after publication, may be submitted through the federal eRulemaking Portal at http://www.regulations.gov. Comments to EBSA should be identified by RIN 1210- AB44; comments to HHS should refer to file code OCIIO-9992-IFC; and comments to the IRS should be identified by REG-120391-1010.

For more information, contact the following: Amy Turner or Beth Baum, EBSA, (202) 693-8335; Karen Levin, IRS, (202) 622-6080; or Jim Mayhew, OCIIO, (410) 786-1565.

For more information on this and related topics, consult the CCH Pension Plan Guide, CCH Employee Benefits Management, and Spencer's Benefits Reports.

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