The Latest Information on Preventive Care: First Dollar Coverage, Frequency Guidelines

PPACA Details ReleasedOn January 9, 2014, the Department of Health and Human Services (HHS), the Department of Labor (DOL) and the Department of the Treasury/IRS issued Frequently Asked Questions – Part XVIII. This document provides additional information about requirements in several areas. In the first of a three-part series, we will break down the details related to preventive care, out-of-pocket limits, and wellness programs.

The requirement that non-grandfathered plans provide first-dollar coverage at 100% includes a provision to update the list of services that must be covered. The FAQ announces that because the United States Preventive Services Task Force (USPSTF) now recommends that breast cancer risk-reducing medications, such as tamoxifen or raloxifene, be prescribed for women who are at increased risk for breast cancer and are at low-risk for adverse medication effects, those medications must be covered at 100% beginning with the first plan year that starts on or after September 24, 2014. This means that calendar year plans must cover those medications (which can be expensive) at 100% in-network under the preventive services benefit starting January 1, 2015.

The FAQ also clarifies that a plan may use reasonable limits on the frequency (but not the dollar amount) of preventive care that it will cover. If the USPSTF recommendations include a frequency, those guidelines should be followed. If there is no guideline, the insurer or health plan may impose a reasonable frequency limit. 

To find out what RX and health care cost-containment strategies other employers are using or planning, complete the UBA Benefit Opinions Survey. You’ll receive a comprehensive findings report that will be especially valuable when complying with the latest PPACA regulations.