Preventive Care

Impacts all nongrandfathered self-funded plans now

The agencies have received many questions about the requirement to provide first-dollar preventive care. They have now issued a FAQ that clarifies that:

• While plans generally do not need to provide out-of-network preventive care if there are no in-network providers able to provide the needed preventive care service, out-of-network care must be provided at no cost
• Preventive over-the-counter drugs, such as aspirin for those at risk for heart attacks, must be covered at 100 percent only if the over-the-counter drug is actually prescribed
• Routine immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) must be covered without cost-sharing beginning with the plan year that begins one year after the recommendation is adopted by the Centers for Disease Control and Prevention (CDC)
• When a screening or immunization recommendation applies only to those who are "high risk," the attending provider is the one who determines if the person is high risk
• If a polyp is removed during a screening colonoscopy, the entire procedure must be covered without cost-sharing, as a preventive service
• The BRAC test itself, as well as genetic testing, must be covered at 100 percent if the attending provider determines the woman is at high risk for the BRAC mutation based on family history
• Required contraceptive coverage does not include male contraceptives
• Plans may not limit coverage to oral contraceptives and must cover IUDs, implants, sterilization, device removal, etc. Plans may impose reasonable management techniques, such as limiting first dollar coverage to generics unless use of the generic would be medically inappropriate for the individual. Over-the-counter contraceptives must be covered only if they are FDA-approved and prescribed by the woman's health care provider
• Annual HIV testing and triennial HPV DNA testing must be covered as part of well-woman care


Out-of-Pocket Limits

Impacts all non-grandfathered self-funded plans beginning with the 2014 plan year

The FAQ also talks about the out-of-pocket maximum requirements. Beginning with the 2014 plan year, plans may not have an out-of-pocket maximum that is larger than the allowed out-of-pocket limit for high-deductible health plans (HDHP) issued in connection with a health savings account. (The out-of-pocket limit includes the deductible, coinsurance and copays. For 2013, the HDHP out-of-pocket limit is $6,250 per person and $12,500 per family.)

The FAQ provides one year of transition assistance to plans that have separate major medical and prescription drug vendors. For the 2014 plan year only, those plans may apply the out-of-pocket limit separately to the major medical and prescription drug parts of coverage. Similar flexibility will not be available to plans with separate mental and nervous benefits, as the Mental Health Parity Act does not allow separate mental and nervous benefit limits.

This information is general and is provided for educational purposes only. It reflects UBA's understanding of the available guidance as of the date shown and is subject to change. It is not intended to provide legal advice. You should not act on this information without consulting legal counsel or other knowledgeable advisors.