by Phil Larson
The preventive care requirements (PHSA 2713) are subject to change as their corresponding requirements change. To fully understand these rules, there are four lists to review:
The rules found under PHSA 2713 do not apply to grandfathered plans but will prevent cost-sharing for these categories for plans that are not grandfathered.
If (or when) any one of these lists change, so will the corresponding requirement to provide this coverage without cost-sharing. Plans should ensure they are keeping up with these lists and making changes to coverage as appropriate. [In fact a recent change was announced for breast cancer in the Annals of Internal Medicine on September 24, 2013].
An important point for plan design is if a recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of that service, the plan or issuer can use reasonable medical management techniques to determine any coverage limitations. Coverage limitations may even include the purchase vs rental of equipment included as coverage.
If you need assistance understanding these rules, please contact Kinney & Larson.
The preventive care requirements (PHSA 2713) are subject to change as their corresponding requirements change. To fully understand these rules, there are four lists to review:
- Evidenced-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 (USPSTF) with respect to the individual involved;
- Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved;
- With respect to 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); and
- With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA, to the extent not already included in certain recommendations of the USPSTF.
The rules found under PHSA 2713 do not apply to grandfathered plans but will prevent cost-sharing for these categories for plans that are not grandfathered.
If (or when) any one of these lists change, so will the corresponding requirement to provide this coverage without cost-sharing. Plans should ensure they are keeping up with these lists and making changes to coverage as appropriate. [In fact a recent change was announced for breast cancer in the Annals of Internal Medicine on September 24, 2013].
An important point for plan design is if a recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of that service, the plan or issuer can use reasonable medical management techniques to determine any coverage limitations. Coverage limitations may even include the purchase vs rental of equipment included as coverage.
If you need assistance understanding these rules, please contact Kinney & Larson.