Coverage of Preventive Services

This rule prohibits health insurers from using cost-sharing mechanisms (such as co-pays, coinsurance, and deductibles) to pay for medical services that have been categorized as "recommended preventive services." The recommended preventive services list¹ includes things like childhood and adult immunizations, cholesterol screening, screening for colorectal cancer, counseling for breastfeeding, recommending aspirin to help with cardiovascular disease, recommending oral fluoride supplementation, and screening for sexually transmitted diseases, to name a few. All non-grandfathered health insurance plans with plan-years commencing after September 23, 2010 are affected by these regulations.

Because patients do not necessarily go to see the doctor for only services listed on the recommended list, the rule determines when the insurance company can use cost-sharing and when they cannot.

The regulation looks at two possible office visit situations:

1. Office visits where the recommended service is charged separately from the office visit itself and


2. Office visits where the recommended service is not charged separately.

In the first case, where recommended services are charged separately, the result is clear. While there will be no cost-sharing on the Recommended Service itself, the insurance company can impose cost-sharing for the office visit.

But, in the second case, where the recommended service is not charged separately, the insurance company can still charge for the visit, but only if the primary purpose of the visit was NOT for the “delivery” of the recommended service.

This regulation applies only to in-network services. Co-pays and the like can still be charged if the insured seeks preventive services outside of the network.

The goal of this rule is to encourage patients to see their doctor for preventive health services without the disincentive of being charged through a co-pay, co-insurance, or a deductible.²

The Obama Administration claims that prohibiting cost-sharing will result in cost savings. The evidence, however shows otherwise. For more information, read our Comment on this regulation which we submitted to the Department of Health and Human Services.

¹ http://www.healthcare.gov/center/regulations/prevention/recommendations.html

² 75 Fed. Reg. 41726, 41731

Note: the Interim Final Rule of August 3, 2011 contains amendments to the Interim Final Rule of July 19, 2010.