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Maine.gov > PFR Home > Insurance Regulation > Health Care Reform

COVERAGE OF PREVENTIVE HEALTH SERVICES

 

The following services must be covered without co-payments, co-insurance, or first having to meet a deductible, also referred to as “cost-sharing”:

  • Services recommended by the US Preventive Services Task Force (a list of these services is available at http://www.healthcare.gov/center/regulations/prevention/taskforce.htm)
  • Immunizations recommended by the Advisory Committee on Immunization Practices of the CDC.
  • Preventive care and screenings for infants, children and adolescents supported by the Health Resources and Services Administration.
  • Preventive care and screenings for women supported by the Health Resources and Services Administration.

 

*This requirement applies only to non-grandfathered plans. Grandfathered plans are health plans in which either a group or an individual was enrolled prior to March 23, 2010. If you are unsure about whether or not your plan is grandfathered, contact your insurance company or your benefits manager.

 

Not all insurance policies have to cover preventive care without cost-sharing. Health plans that were in place before the new health care law was signed on March 23, 2010, are grandfathered, and they are not required to cover preventive care. Plans that were purchased between March 23 and Sept. 23, 2010, do not have to cover preventive care right away (see below for more details and examples). Plans that are purchased after Sept. 23, 2010, do have to cover preventive care at no cost.

 

Below are a few examples to illustrate when and if certain plans will include preventive coverage without cost-sharing.

 

FOR INDIVIDUALS

 

EXAMPLE 1: You purchased your insurance for yourself and your children in January of 2010. Your policy is grandfathered. Your plan IS NOT required to cover preventive care without cost-sharing.

 

EXAMPLE 2: You purchased insurance for yourself and your children in the individual insurance market on March 30, 2010. Your plan is NOT grandfathered, but you might have to wait to receive preventive services without cost-sharing until a later date.

 

The date that you will have no cost-sharing depends on a few things: If your insurer has specified a "policy year" for your coverage, the new provisions will become effective on that date. Otherwise, the new benefits and protections will be added on the date when annual deductibles and annual limits reset each year. If your policy does not have an annual deductible or annual limit, these changes will become effective on Jan. 1, 2011. If you have questions about when these provisions will become effective for your policy, contact your insurance company.

 

EXAMPLE 3: You purchased insurance for yourself and your children in the individual insurance market on Sept. 24, 2010. Your policy is not grandfathered, and the new plan must include preventive services with no cost-sharing.

 

FOR CONSUMERS WHO HAVE JOB-BASED COVERAGE

 

EXAMPLE 1: You enrolled in your employer’s group health plan in April of 2010, but the plan is grandfathered because it was purchased in 2000. It is not required to cover preventive care without cost-sharing.

 

EXAMPLE 2: You started a new job in April of 2010 at a company that started offering insurance after March 23, 2010. The plan is NOT grandfathered. Your employer’s coverage renews on January 1. Because the plan is not grandfathered, the employer will be required to cover preventive services starting on January 1, 2011.

 

Last Updated: May 27, 2014