Recommended Preventative Services from HHS, Treasury and Labor

By Larry Grudzien, JD

The Departments of Health and Human Services (HHS), Labor, and Treasury issued interim final regulations on July 14, 2010 requiring new plans and issuers to cover certain preventive services without any cost-sharing for the enrollee when delivered by in-network providers.  The interim final regulations do not apply to grandfathered plans and issuers.   This website provides links to the items and services that must be covered under this interim final regulation.  It is organized by the recommending body.

Unless noted otherwise below, the recommended services must be provided without cost-sharing when delivered by an in-network provider in the plan years (in the individual market, policy years) that begin on or after September 23, 2010. For recommendations that have been in effect for less than one year, plans and issuers will have one year from the effective date to comply.

For any recommendation that went into effect after September 23, 2009, additional information and relevant dates are provided below. 

Recommendations of the United States Preventive Services Task Force (USPSTF)

Recommendations of the USPSTF appear in a chart, which includes a description of the topic, the text of the USPSTF recommendation, the grade the recommendation received (A or B), and the date that the recommendation went into effect.

Complete List of USPSTF Grade A and B Recommendations

The following recommendations went into effect in whole or in part at some point after September 23, 2009:

· Screening and counseling for obesity: children (in effect January 31, 2010)

The recommendation on screening and counseling for obesity in children went into effect on January 31, 2010.  For this service, plans and issuers are required to provide coverage without cost-sharing in the first plan year (in the individual market, policy year) that begins on or after January 31, 2011.

Learn more about the USPSTF, the process it uses to make recommendation, or the evidence reviews for a specific recommended service.

Recommendations of the Advisory Committee On Immunization Practices (ACIP) That Have Been Adopted by the Director of the Centers for Disease Control and Prevention

Recommendations of the ACIP appear in four immunization schedules for 2010.  The schedules contain graphics that provide information about the recommended age for vaccination, number of doses needed, interval between the doses, and (for adults) recommendations associated with particular health conditions.  In addition to the graphics, the schedules contain detailed footnotes that provide further information on immunizations in the schedule.

Recommended Immunization Schedule for Persons Aged 0 Through 6 Years

Recommended Immunization Schedule for Persons Aged 7 Through 18 Years

Catch-up Immunization Schedule for Persons Aged 4 Months Through 18

Years Who Start Late or Who Are More Than 1 Month Behind

Recommended Adult Immunization Schedule

The following recommendations went into effect in whole or in part at some point after September 23, 2009:

· Meningococcal vaccine (in effect September 25, 2009)

An expanded recommendation on meningococcal vaccine went into effect on September 25, 2009.  The new recommendation only differs with respect to revaccination of individuals at increased risk.  The prior recommendation had addressed revaccination for certain individuals who had previously received meningococcal polysaccharide vaccine; the new recommendation extends this to certain individuals who had previously received meningococcal conjugate vaccine.  Therefore, plans and issuers with plan years (in the individual market, policy years) that begin on or after September 23, 2010 but before September 25, 2010 are required to provide coverage without cost-sharing for this service as described in the 2010 schedules, except that they are not required to provide coverage without cost-sharing for revaccination of certain individuals who had previously received meningococcal conjugate vaccine.  Plans and issuers are required to provide coverage without cost-sharing for this service exactly as described in the 2010 schedules in the first plan year (in the individual market, policy year) that begins on or after September 25, 2010.

· HPV (in effect January 8, 2010)

An expanded recommendation on HPV vaccine went into effect on January 8, 2010.  The new recommendation addresses vaccination with the bivalent (as opposed to quadrivalent) HPV vaccine for the first time; prior to January 8, 2010, the Advisory Committee did not make any recommendation on the bivalent vaccine.  The new recommendation also addresses vaccination of males for the first time; prior to January 8, 2010, the ACIP did not make any recommendation on the vaccination of males. Therefore, plans and issuers with plan years (in the individual market, policy years) that begin on or after September 23, 2010 but before January 8, 2011 are required to provide coverage without cost-sharing for this service as described in the 2010 schedules, except that they are not required to provide coverage without cost-sharing for vaccination with the bivalent vaccine or for vaccination of males.  Plans and issuers are required to provide coverage without cost-sharing for this service exactly as described in the 2010 schedules in the first plan year (in the individual market, policy year) that begins on or after January 8, 2011.

· Influenza (in effect March 2, 2010)

An expanded recommendation on influenza vaccine went into effect on March 2, 2010.  Plans and issuers will be required to provide coverage without cost-sharing for this service as described in the recommendation and in the 2011 schedules in the first plan year  (in the individual market, policy year) that begins on or after March 2, 2011.  Read the full text of the recommendation.

· Pneumococcal vaccine (in effect March 12, 2010)

An expanded recommendation on pneumococcal vaccine went into effect on March 12, 2010.  Plans and issuers will be required to provide coverage without cost- sharing for this service as described in the recommendation and in the 2011 schedules in the first plan year  (in the individual market, policy year) that begins on or after March 12, 2011.  Read the full text of the recommendation.

NOTE: Infection with Streptococcus pneumoniae bacteria can make children very sick. It causes blood infections, pneumonia, and meningitis, mostly in young children. Although pneumococal meningitis is relatively rare (less than 1 case per 100,000 people each year), it is fatal in about 1 of 10 cases in children.  Before routine use of pneumococcal conjugate vaccine, pneumococcal infections caused: over 700 cases of meningitis, 13,000 blood infections, about 5 million ear infections, and about 200 deaths annually in the United States in children under five.  There are more than 90 types of pneumococcal bacteria. The new pneumococcal conjugate vaccine (PCV13) protects against 13 of them. These bacteria types are responsible for most severe pneumococcal infections among children. PCV13 replaces a previous conjugate vaccine (PCV7), which protected against 7 pneumococcal types and has been in use since 2000. During that time severe pneumococcal disease dropped by nearly 80% among children under 5.

· Combination Measles, Mumps, Rubella, and Varicella Vaccine (in effect May 7, 2010)

A new recommendation related to combination measles, mumps, rubella, and varicella vaccine went into effect on May 7, 2010.  Plans and issuers will be required to provide coverage without cost sharing for this service as described in the recommendation and in the 2011 schedules in the first plan year (in the individual market, policy year) that begins on or after May 7, 2011.  Read the full text of the recommendation.

Learn more about the ACIP, the process it uses to make recommendation, or information associated with particular immunizations.

Comprehensive Guidelines Supported by the Health Resources and Services Administration (HRSA)

Comprehensive guidelines for infants, children, and adolescents supported by HRSA appear in two charts: the Periodicity Schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care, and the Uniform Panel of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children.

Bright Futures Recommendations for Pediatric Preventive Health Care

The comprehensive guidelines that are illustrated in the Periodicity Schedule of the Bright Futures Recommendations for Pediatric Preventive Health Care went into effect before September 23, 2009; therefore, plans and issuers are required to provide coverage without cost sharing for these services in the first plan year (in the individual market, policy year) that begins on or after September 23, 2010.

Learn more about the Bright Futures project or find more information about their recommended preventive services

Recommendations of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children

The comprehensive guidelines that are illustrated in the Uniform Panel of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children went into effect May 21, 2010.  Plans and issuers are required to provide coverage without cost-sharing for these services in the first plan year (in the individual market, policy year) that begins on or after May 21, 2011.

Learn more about the Secretary’s Advisory Committee and view its reports

HealthCare.gov fact sheet on recommended preventive services:

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

HealthCare.gov webpage with preventive services resources:

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

 

If you have any comments or questions regarding any of above information, please do not hesitate to call (708) 717-9638 or e-mail larry@larrygrudzien.com

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