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Employer Health Reform Issues Brief: Mandatory Coverage of Preventive Services

Smart first steps for employers


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The Provision

Group health plans other than grandfathered plans will be required to cover certain preventive services, and no cost-sharing (including deductibles, co-pays, and co-insurance) will be permitted for this coverage. Specifically, this mandate will apply to the following preventive care and other services:

  • Preventive services with an ‘A’ or ‘B’ rating by the U.S. Preventive Services Task Force;
  • Immunizations recommended by the Center for Disease Control’s Advisory Committee on Immunization Practices with respect to the individual involved;
  • For infants, adolescents, and children, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and
  • Additional preventive care and screenings for women provided for in comprehensive guidelines supported by the HRSA.

The U.S Preventive Service Task Force’s November 2009 recommendations regarding breast cancer screening, mammography, and prevention are not to be taken into account for purposes of this requirement.

Plans will be given at least one year to implement periodic changes to the relevant ratings, guidelines, and recommendations described above.

Effective Date: Plan years beginning on or after September 23, 2010. Does not apply to grandfathered plans.

Key Implication: Plan Design

Plans will need to provide first-dollar coverage for preventive services. Even plans that already offer comprehensive coverage of preventive services may need to be modified to ensure compliance with the specifics of the new mandate.

Key Implication: Cost

The new mandate will increase short-term costs for plans that need to add coverage or eliminate cost-sharing provisions. The long-term cost implications are uncertain, and will depend on whether and to what extent the cost of providing the mandated coverage is offset by savings from prevention or early detection of certain conditions.

Smart First Steps

Plan Design: Evaluate plans to determine what, if any, changes will be needed to comply with the new mandate. Remember that any cost-sharing – deductibles, co-pays, and co-insurance payments – with respect to the mandated preventive care and other services must be eliminated as well.

Cost: Assess the cost impact of any required plan changes, including the possibility of reducing long-term costs. Consider other plan design changes that might be implemented to offset any expected additional costs.

Communications: Educating employees about the appropriate use of preventive care services can be an important part of a successful overall wellness program. Consider communications strategies to promote use of preventive care services to improve participants’ health, potentially leading to lower long-term health costs for the plan. Update Summary Plan Description (SPD) and other plan communication materials to reflect any changes to plan design.

What Preventive Services Will Plans Have to Cover?

The mandate applies to preventive services with an ‘A’ or ‘B’ rating by the U.S. Preventive Services Task Force. A partial list of these in effect for 2009 includes screening for:

  • Abdominal Aortic Aneurysm
  • Breast Cancer
  • Cervical Cancer
  • Colorectal Cancer
  • Depression
  • High Blood Pressure
  • HIV
  • Lipid Disorders in Adults
  • Obesity in Adults
  • Osteoporosis in Postmenopausal Women
  • Type 2 Diabetes Mellitus in Adults

A complete list is available on the U.S. Preventive Services Task Force’s Web site, at www.ahrq.gov/clinic/uspstfix.htm. The immunization recommendations of the CDC’s Advisory Committee on Immunization Practices are available at www.cdc.gov/vaccines/recs/acip/default.htm. The HRSA web site is at www.hrsa.gov.

As used in this document, “Deloitte” means Deloitte Consulting LLP, a subsidiary of Deloitte LLP. Please see www.deloitte.com/us/about for a detailed description of the legal structure of Deloitte LLP and its subsidiaries.

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