Although group health plans that are not grandfathered under the Patient Protection and Affordable Care Act typically must provide coverage with no cost sharing for recommended preventive care services, there are situations in which a plan may impose a deductible, copay or coinsurance. For example, a plan may require cost sharing for a preventive care service:

• if the service is not recommended by the specified recommending body;
• if the service is covered and provided out-of-network; or
• during the implementation period allowed after a service gains “recommended” status.

Plans must apply any changes to recommendations in the plan year that begins one year after a new, revised, or enhanced recommendation or guideline is issued. Thus, a calendar year plan must implement screening and counseling for obesity in children, guidelines recommended on January 31, 2010, in the 2012 plan year and Health Resources and Services Administration-supported guidelines for women’s preventive services, guidelines effective on August 1, 2011, in the 2013 plan year.

Once a service is dropped from any of the lists, a plan may require cost sharing for that service, subject to notice requirements for material modifications (once implemented), other federal or state laws and, of course, practical considerations regarding plan operation.

If coverage limitations are not specified by a recommendation or guideline, a plan may use reasonable medical management techniques to control costs and promote efficiency. For example, the plan could require cost sharing for a brand-name version of a drug if a generic version is available and safe.

Plans should check the lists of recommendations and guidelines at http://www.healthcare.gov/center/regulations/prevention.html each year to determine if there are changes to the lists, to begin planning for implementation of those changes, and to review and apply options for controlling costs.

For a discussion of the requirement to provide preventive care services without cost-sharing, see 389 T.M., Medical Plans – COBRA, HIPAA, HRAs, HSAs and Disability.

-- Nadia Masri, Tax Law Editor (Compensation Planning)