Preventive services at no cost: what the plan must cover and what it may not.
Non-grandfathered group health plans must cover a defined list of preventive services without cost sharing. The list comes from federal advisory bodies, and the network is where plans keep some flexibility.
What is on the list.
USPSTF A And B Recommendations
Evidence-based items and services with an A or B rating in the current recommendations of the U.S. Preventive Services Task Force. The recommendation lists change over time, so employers should ask the carrier or plan administrator how it applies the current lists and when new items take effect for the plan year. You can test your own figures with our renewal cost sharing calculator.
Routine Immunizations
Immunizations recommended for routine use in children, adolescents and adults by the Advisory Committee on Immunization Practices and adopted by the CDC Director. Plans typically follow the schedule when deciding what to cover, so employers should confirm with the carrier which vaccines, doses and age ranges are included and how the plan handles in-network and out-of-network providers.
Children And Adolescents
Evidence-informed preventive care and screenings for infants, children and adolescents from HRSA-supported guidelines. Coverage depends on the age of the child and the plan’s rules, so employers should check how well-child visits, screenings and vaccines are handled and how they are explained in employee materials.
Women
Evidence-informed preventive care and screenings for women from HRSA-supported guidelines. Employers should confirm how the plan handles items such as well-woman visits and screenings, and how the carrier applies the guidelines, since details can change. Ask the carrier for its current preventive list in writing.
What must be covered with no cost sharing.
Recommended Screenings
Evidence based services with an A or B rating from the U.S. Preventive Services Task Force must be covered without copayments, coinsurance or deductibles. Whether an item is covered without employee cost sharing can depend on whether the service is delivered in network and is billed as preventive, so employees benefit from clear guidance on how to schedule them.
Immunizations
Routine immunizations recommended by the CDC’s Advisory Committee on Immunization Practices, once adopted by the CDC and listed on its schedules. Employers should ask the carrier how new or updated recommendations are added during the year, and make sure open enrollment and summary materials describe the preventive benefit accurately and without overpromising.
Children And Adolescents
Preventive care and screenings in the comprehensive guidelines supported by the Health Resources and Services Administration. Plans commonly cover recommended visits, screenings and developmental checks, but the details depend on the plan. Employers can ask the carrier to supply a plain-language summary that families can use at enrollment.
Women’s Preventive Care
Additional preventive care and screenings for women under the same agency’s guidelines, subject to the related religious and moral exemption rules. Because the guidelines and the plan’s own rules both matter, employers should review how services such as screenings and counseling are described to employees, and confirm the details with the carrier or counsel.
Office Visits
If the preventive service is billed separately, the visit may carry cost sharing. If it is not billed separately and the main purpose of the visit is the preventive service, the visit cannot. Employees do better when they know to ask how a visit will be billed before they go, and the carrier can explain how the plan treats it.
Network And Medical Management
A networked plan can limit no cost coverage to in-network providers unless none can deliver the service, and can use reasonable medical management for frequency, method, treatment or setting when the guideline is silent. Employers should still make sure employees know how to find an in-network provider and how to ask the carrier about exceptions.
Source: 29 CFR 2590.715-2713.
Applying it to your plan.
Confirm Grandfathered Status
DOL says the rule does not apply to grandfathered plans. Know which category your plan is in. Grandfathered status depends on the plan’s history and on changes made since the original date, so ask the carrier or counsel to confirm it in writing and keep that record on file.
Check Office Visits
If a recommended service is not billed separately and is the primary purpose of the visit, cost sharing cannot apply to the visit. Coding and billing practices can affect what the employee pays, so it helps to have the carrier explain in plain terms how it treats visits that include more than one service.
Watch The Network Caveat
Plans with a network are not required to cover recommended preventive services from out-of-network providers, and may apply cost sharing to them. Where no in-network provider can deliver a recommended service, the plan may have to cover an out-of-network option, so employees should know how to ask the carrier about that.
Re-Check When The Lists Change
The recommendations are updated over time, so ask your carrier how changes are adopted. Set a reminder to review the plan’s preventive list each year at renewal, and ask the carrier to confirm what changed and when, so open enrollment materials stay accurate.
Three questions for your carrier.
How Do You Code Preventive Visits
Errors in coding are the usual cause of surprise bills for preventive care. Employers can help by giving employees a short guide on telling the provider that a visit is preventive, and by asking the carrier to review claims that appear to be coded incorrectly.
What Does Our Plan Do For Out-Of-Network
Know your plan’s approach so you can tell employees. Ask the carrier to state in writing how out-of-network preventive services are paid, and share a short plain-language summary with employees at enrollment so they can plan ahead and avoid surprise bills.
Is Our Plan Grandfathered
The answer changes the rule. Grandfathered status can change when a plan makes certain changes to benefits or cost sharing, so ask the carrier to confirm your plan’s status and keep the answer with your plan records. Plan changes made over the years, such as shifting costs or trimming benefits, can matter, so gather the plan history before relying on the answer.
Common Questions About Preventive Services
Who decides what counts as preventive?
The USPSTF, ACIP and HRSA-supported guidelines, as DOL describes them.
Can the plan charge a copay for a preventive visit?
Not if the service is not billed separately from the visit and is the primary purpose of the visit.
Does it apply to out-of-network care?
No. Plans with networks are not required to cover recommended preventive services out of network and may impose cost sharing.
Does a grandfathered plan have to cover them?
No. DOL says the preventive services requirement does not apply to grandfathered plans.
Is a diagnostic test the same as a screening?
Not for these rules. If symptoms or a known problem prompt a test, it may be billed as diagnostic. Ask your carrier.
Is this legal advice?
No. For your own plan, involve your counsel. We can help you check your plan against the list.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents — two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
Laws and rules referenced
42 U.S.C. § 300gg-13 — Coverage of preventive services without cost sharing.
This page is general information, not legal or tax advice. Rules change and facts matter, so confirm your situation with counsel or a qualified advisor.
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