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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.

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