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Your company has a group health plan renewing in 2011, which currently has a 100-percent preventive benefit with a combined in- and out-of-network annual maximum of $450. In light of health care reform and its requirement to eliminate cost-sharing for preventive care, may you now maintain an out-of-network cap of $450 and remove the cap for in-network only?
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Answer: |
Yes. The Employee Benefits Security Administration, the Internal Revenue Service, and the Department of Health and Human Services issued regulations under the Patient Protection and Affordable Care Act (PPACA) requiring private health plans to cover evidence-based preventive services and to eliminate cost-sharing for preventive care. New health policies beginning on or after September 23, 2010, must cover preventive services that have a strong scientific evidence of their health benefits. Also, plans can no longer charge a patient a copayment, coinsurance or deductible for these services when they are delivered by a network provider.
Covered preventive services include screenings for diabetes, high cholesterol and high blood pressure, tobacco cessation counseling, and certain routine vaccines.
However, under the PPACA's preventive care rules, a plan that has a network of providers is not required to provide required preventive services that are delivered by an out-of-network provider. In addition, a plan that has a network of providers may impose cost-sharing requirements for required preventive services that are delivered by an out-of-network provider. Therefore, yes, an employer can maintain an out-of-network cap of $450.
Source: IRS, EBSA, HHS interim final regulations, Federal Register, July 19, 2010.
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