Reform Alert - News from the Blues' Office of National Health Reform

Regulations released for immunizations and preventive coverage with no cost-sharing

August 3, 2010

The Departments of Health and Human Services (HHS), Labor, and Treasury issued new Patient Protection and Affordable Care Act (PPACA) regulations on July 14, 2010, requiring that private health plans cover evidence-based preventive services and immunization with no cost-sharing. These requirements only apply to services provided by in-network providers. Blue Cross Blue Shield of Michigan and Blue Care Network already provided many of these services with little or no cost-sharing prior to passage of PPACA.

The regulations, which are available on the HHS health care reform website, state that preventive coverage, such as recommended vaccinations, health screenings and children’s wellness visits, must be covered for all new health plans starting with plan years beginning on or after Sept. 23, 2010. BCBSM and BCN are working to implement these provisions for all group and individual health plans.

Services that must be covered with no cost-sharing include:

Evidence-based preventive services: The U.S. Preventive Services Task Force (USPSTF), an independent panel of experts, rates preventive coverage based on scientific evidence documenting their benefits, including preventive services with a “grade” of A or B, such as:

  • Certain screenings for cancer 
  • Vitamin deficiencies during pregnancy 
  • Diabetes 
  • High cholesterol 
  • High blood pressure 
  • Depression 
  • Counseling for tobacco cessation 

Routine immunizations: Health plans will cover a set of standard vaccines recommended by the Advisory Committee on Immunization Practices (ACIP) for routine use ranging from routine childhood immunizations to periodic tetanus shots for adults.

Prevention for children: Health plans will cover preventive care for children up to age 21 described in guidelines from the Health Resources and Services Administration (HRSA) and the American Academy of Pediatrics, including:

  • Regular pediatrician visits 
  • Vision and hearing screening 
  • Developmental assessments 
  • Immunizations and screening 
  • Counseling to address obesity 

Prevention for women: Health plans will cover preventive care and screening provided to women according to guidelines supported by HRSA that are not otherwise addressed by the USPSTF recommendations. HHS is developing further guidance on this requirement, which it expects to issue by Aug. 1, 2011.

When new services are added to the recommendations, health plans will be required to cover the services for plan years that begin one year after the date of the new recommendation.

Specifics about cost-sharing:

Cost-sharing, such as copayments, coinsurance or deductibles, for in-network provider office visits may be charged, depending on how providers bill.

  • If it the preventive service, item or immunization is billed separately from the office visit, cost-sharing may be applied to the visit but not to the preventive service, item or immunization. 
  • If the primary purpose of the visit is to receive recommended preventive services, items or immunizations, and they are not billed separately, the member may not be charged cost-sharing for the visit. 
  • If the primary purpose of the visit is for anything other than to receive preventive services, items or immunization, the member may be charged for the office visit, even if a preventive service or immunization is provided. 
  • Optional preventive services, preventive services related to, but not included in the USPSTF, ACIP or HRSA list of recommendations, and services that have been removed from these lists may be provided with cost-sharing. 
  • Preventive services provided by out-of-network providers do not have to be covered. If they are covered, they do not have to be covered with no cost-sharing. 

BCBSM and BCN are thoroughly analyzing the impacts of these regulations and will provide specific information regarding implementation at a future date.

The information on this website is based on BCBSM's review of the national health care reform legislation and is not intended to impart legal advice. Interpretations of the reform legislation vary, and efforts will be made to present and update accurate information. This overview is intended as an educational tool only and does not replace a more rigorous review of the law's applicability to individual circumstances and attendant legal counsel and should not be relied upon as legal or compliance advice. Analysis is ongoing and additional guidance is also anticipated from the Department of Health and Human Services. Additionally, some reform regulations may differ for particular members enrolled in certain programs such as the Federal Employee Program, and those members are encouraged to consult with their benefit administrators for specific details.

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