Reform gets more expensive: What you must pay for now

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Keeping healthcare costs down just became more daunting for employers — at least in the short term.
The feds just issued interim final regulations explaining the preventive services health plans must offer to participants without any co-pays, co-insurance or deductible requirements attached to them.
By encouraging individuals to seek preventive care — by reducing what they’d have to pay to get the care — the feds believe it’ll keep individuals healthier, and thus lower employer’s healthcare costs in the long term.
Regs aren’t exactly clear
There’s one problem with the feds’ plan, however. A consortium of government agencies have been tasked with determining which services actually fall under the category “preventive.” And rather than spell these services out, the feds are asking health plan administrators to refer to an array of continuous recommendations by these agencies.
Here are just a few examples of the preventive services that must be covered without cost-sharing arrangements (co-pays, deductibles, etc.) with employees:

  • Screenings — for things like high blood pressure, HIV, diabetes, hearing loss, etc.
  • Routine immunizations of children, adolescents or adults — for things like Influenza, Hepatitis A & B, and
  • Preventive care/screenings — for infants, children adolescents and women. Note: Preventive care guidelines for women will not be issued until the summer of 2011.

The guidelines — along with the services that must be covered — will be updated on an ongoing bases, and health plans are required to comply with any changes in plan years beginning the year after the changes are published.
Exceptions to the rule
Of course, there are several exceptions to the new preventive care regs.
For example, grandfathered health plans are not required to cover 100% of the cost of preventive care services.
In addition, there are certain situations where cost-sharing is permitted (for those plans that aren’t grandfathered).
For example, if an individual goes to the doctor for multiple reasons (including preventive services) and the preventive care is not the primary reason for the visit, cost-sharing is allowed.
And services provided by out-of-network practitioners also don’t have to be covered.