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Can We Impose Cost Sharing for Out-of-Network Preventive Services?

03.11.2020

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

Answer: A nongrandfathered 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, co-payments, co-insurance or other cost sharing may be imposed on these in-network services. This requirement doesn’t 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 aren’t 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 doesn’t have in its network a provider who can provide a particular preventive service, 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 lacks a provider in its network. Contact your benefits advisor for further specifics.

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