Skip to content

Our Privacy Statement & Cookie Policy

All Thomson Reuters websites use cookies to improve your online experience. They were placed on your computer when you launched this website. You can change your cookie settings through your browser.


Can Our Major Medical Plan Impose Cost-Sharing for Preventive Services Delivered by Out-of-Network Providers?



QUESTION: Our company’s major medical plan provides in-network and out-of-network coverage. It is not grandfathered and, therefore, is subject to the prohibition against cost-sharing for preventive services. Can our plan impose cost-sharing for preventive services that are delivered by out-of-network providers?

ANSWER: A non-grandfathered group health plan generally can impose cost-sharing on preventive services delivered by out-of-network providers. The Affordable Care Act generally requires group health plans to provide coverage for certain preventive services delivered by in-network providers without cost-sharing. (This is sometimes referred to as providing “first-dollar coverage.”) Thus, no deductibles, copayments, coinsurance, or other cost-sharing may be imposed on these in-network services. This requirement does not apply to grandfathered plans, or to excepted benefits such as limited-scope dental or vision coverage provided under a separate insurance contract.

Plans that use a network of providers to provide preventive services are not required to cover preventive services delivered by out-of-network providers and can impose cost-sharing requirements if out-of-network preventive services are covered. However, this provision is premised on individuals being able to access the required preventive services from in-network providers. If a plan does not have in its network a provider who can provide a particular preventive service, then it must cover the item or service when performed by an out-of-network provider and not impose cost-sharing. For example, a plan must cover out-of-network lactation counseling as a preventive service without cost-sharing if the plan does not have a provider in its network.

For more information, see EBIA’s Health Care Reform manual at Section XII.C (“Coverage of Preventive Health Services”); see also EBIA’s Group Health Plan Mandates manual at XIV.C (“Required Preventive Health Services Coverage”) and EBIA’s Self-Insured Health Plans manual at Section XIII.C.1 (“Preventive Health Services”).

Contributing Editors: EBIA Staff.

More answers