3
MHPAEA, plans and issuers are prohibited from imposing an annual out-of-pocket maximum on
all medical/surgical benefits and a separate annual out-of-pocket maximum on all mental health
and substance use disorder benefits.
Coverage of Preventive Services
PHS Act section 2713 and the interim final regulations
5
require non-grandfathered group health
plans and health insurance coverage offered in the individual or group market to provide benefits
for and prohibit the imposition of cost-sharing requirements with respect to, the following:
Evidenced-based items or services that have in effect a rating of “A” or “B” in the current
recommendations of the United States Preventive Services Task Force (USPSTF) with
respect to the individual involved;
Immunizations for routine use in children, adolescents, and adults that have in effect a
recommendation from the Advisory Committee on Immunization Practices (ACIP) of the
Centers for Disease Control and Prevention (CDC) with respect to the individual
involved;
With respect to infants, children, and adolescents, evidence-informed preventive care and
screenings provided for in the comprehensive guidelines supported by the Health
Resources and Services Administration (HRSA); and
With respect to women, evidence-informed preventive care and screening provided for in
comprehensive guidelines supported by HRSA, to the extent not already included in
certain recommendations of the USPSTF.
6
If a recommendation or guideline does not specify the frequency, method, treatment, or setting
for the provision of that service, the plan or issuer can use reasonable medical management
techniques to determine any coverage limitations.
7
These requirements do not apply to grandfathered health plans.
8
Out-of-Network Services Generally
Q3: My plan does not have any in-network providers to provide a particular preventive
service required under PHS Act section 2713. If I obtain this service out-of-network, can
the plan impose cost-sharing?
No. While nothing in the interim final regulations generally requires a plan or issuer that has a
network of providers to provide benefits for preventive services provided out-of-network, this
5
75 FR 41726 (July 19, 2010).
6
“Women’s Preventive Services: Required Health Plan Coverage Guidelines” (HRSA Guidelines) were adopted and
released on August 1, 2012, based on recommendations developed by the Institute of Medicine (IOM) at the request
of HHS. These recommended women’s preventive services are required to be covered without cost-sharing, for plan
years (or, in the individual market, policy years) beginning on or after August 1, 2012.
7
See 26 CFR 54.9815-2713T(a)(4), 29 CFR 2590.715-2713(a)(4), 45 CFR 147.130(a)(4).
8
Certain non-grandfathered, non-profit religious organizations are not required to cover the contraceptive services
recommendation that is part of the HRSA guidelines. For information on these entities, see 77 FR 8725 and
http://cciio.cms.gov/resources/files/prev-services-guidance-08152012.pdf. See also proposed rules published on
February 6, 2013, at 78 FR 8456.