SHORT - Preventive Care

Preventive Care Rules


Who:   All individual policies, group insured plans, and self-insured plans that are not grandfathered. To be a grandfathered health plan, a group health plan or individual coverage must have been in effect on March 23, 2010, the date of the Act’s enactment.  Changes made since March 23, 2010 to the plan benefits or pricing may invalidate the grandfather status.


When: Plan years beginning on or after 9/23/2010; for most plans, this date is likely January 1, 2011


Executive Summary:  Plans must cover without cost-sharing requirements preventive services as graded “A” or “B” by the U.S. Preventive Services Task Force, certain immunizations; preventive services for infants, children, adolescents and women as provided in guidelines developed by HHS’s Health Resources and Services Administration.


At a minimum plans non-grandfathered plans must provide coverage for and shall not impose any cost sharing requirements for:


(1)   Evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force;


(2)   Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention.


(3) For infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health

Resources and Services Administration (HRSA).


(4) For women, such additional preventive care and screenings not described in paragraph (1) as provided for in comprehensive guidelines supported by the Health

Resources and Services Administration.


Depending on age and health plan type, plan members may gain full coverage access to such services as:

·         Blood pressure, diabetes, and cholesterol tests;

·         Many cancer screenings;

·         Counseling from your health care provider on such topics as quitting smoking, losing weight, eating better, treating depression, and reducing alcohol use;

·         Routine vaccines for diseases such as measles, polio, or meningitis;

·         Flu and pneumonia shots;

·         Counseling, screening and vaccines for healthy pregnancies; and

·         Regular well-baby and well-child visits, from birth to age 21.


Action Required:  Most employers will want to discuss the new legislation with their insurer, TPA, agent, broker, or benefit consultant.  The complete list of recommendations and guidelines for services that are required to be covered under the Regulations can be found at the Implementation Center. This website will be updated on an ongoing basis and will contain the most current recommended preventive services. If the list is updated to add or change any of the recommended preventive services, the changes will be effective for plan years beginning on or after the date that is one year after the date that the change is issued. A direct link to the USPSTF is:

The information presented and contained within this article was submitted by Ronald E. Bachman, President and CEO of Healthcare Visions. This information is general information only, and does not, and is not intended to constitute legal advice. You should consult your legal advisors to determine the laws and regulations impacting your business.