By Jessica Faith, © Faegre Baker Daniels
With 2013 around the corner, one new requirement that will be in effect on January 1 for calendar-year nongrandfathered group health plans is the coverage of certain women’s preventive services without cost-sharing. The coverage requirement is effective for plan years beginning on or after Aug. 1, 2012, and does not apply to grandfathered group health plans.
The guidelines on women’s preventive services require plans to provide coverage for the following types of preventive services without co-payments or other cost-sharing:
• Well-woman visits—Annually, with additional visits as necessary.
• Screening for gestational diabetes—Between weeks 24-28 of gestation, and at the first prenatal visit for high-risk women.
• Testing for HPV—Every three years beginning at age 30.
• Counseling for sexually transmitted infections—Annually.
• Counseling and screening for HIV—Annually.
• FDA-approved contraceptive methods, sterilization procedures, and counseling—Annually, subject to certain religious-employer exemptions.
• Breastfeeding support, supplies and counseling—With each birth.
• Screening and counseling for interpersonal and domestic violence—Annually.
Detailed information about each type of service is available at the HHS website.
Out of Network Providers
The requirement to cover the preventive services without cost-sharing does not apply to services that are performed out-of-network; if a participant receives the preventive services at an out-of-network provider, cost-sharing can be imposed.
In addition, the agencies have given plans allowance to use “reasonable medical management techniques” to determine the frequency, method, treatment, or setting for the preventive services, to the extent that those items are not covered in the preventive-services guidelines.
Open questions remain regarding the coverage of women’s preventive services—for example, what type of breastfeeding supplies are eligible to be covered? Plan sponsors should continue to watch for guidance and should work with their insurers and administrators on implementing the new preventive requirements.
Jessica Faith is an associate in the ERISA, benefits and executive compensation practice at law firm Faegre Baker Daniels.
© 2011 Faegre Baker Daniels LLP. All rights reserved.
This article should not be construed as legal advice.
Major Health Care Reform Deadlines Loom, SHRM Online Legal Issues, October 2012
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