February 28, 2013
Authored by: Chris Rylands and Serena Yee
As discussed in our prior post, the Department of Treasury/IRS, Department of Labor, and the Department of Health and Human Services (the “Departments”) recently issued its twelfth set of Frequently Asked Questions addressing cost-sharing limitations and a slew of preventive services issues. The cost-sharing rules are covered in our prior post; here, we’ll discuss the preventive care rules. By way of reminder, non-grandfathered group health plans are required to cover specified preventive services. The FAQs address some open questions that were not addressed in the regulations.
Out-of-Network Services. A plan with a network is generally not required to cover preventive services out-of-network without cost-sharing. However, if a preventive service is not available from any in-network provider, then the FAQs say a plan cannot impose cost-sharing when it is obtained from an out-of-network provider.
Over-the-Counter Medications. The FAQs make clear that plans do have to cover OTC items and services that are part of the preventive care recommendations (e.g. aspirin for those at risk for heart disease), unless those items or services are prescribed by a health care provider.
Polyps. The FAQs state that if a polyp is removed as part of a colonoscopy, the plan may not impose cost-sharing for the polyp removal. The Departments based their determination on clinical practice and comments from various professional medical associations indicating that polyp removal is an integral part of a colonoscopy.
In contrast, plans can impose cost-sharing for a treatment that is not a specified preventive service,