Sec. 31.11.06.03-1. Covered Services — Preventive Care Services

A. This regulation applies to plans with plan years that begin on or after September 23, 2010.

B. The benefits required by Regulation .03A(9), (9-1), (9-2), (10), (31) and (33), Regulation .04F(5)(e) and (6)(e), and Regulation .05I of this chapter do not apply to plans with plan years that begin on or after September 23, 2010.

C. Plans that are subject to this regulation shall provide benefits for the following preventive care services:

(1) Except as provided in §D of this regulation, evidence–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;

(2) Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved;

(3) 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; and

(4) With respect to women, to the extent not described in §C(1) of this regulation, evidence-informed preventive care and screenings as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

D. For the purposes of §C(1) of this regulation, recommendations of the United States Preventive Services Task Force regarding breast cancer screening, mammography, and prevention issued in or around November 2009 are not considered to be current.

E. For the purposes of §C(2) of this regulation, a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered to be:

(1) In effect after it has been adopted by the director of the Centers for Disease Control and Prevention; and

(2) For routine use if it is listed on the immunization schedules of the Centers for Disease Control and Prevention.

F. Cost Sharing Requirements.

(1) Except as described §F(2) and (3) of this regulation, a carrier may not impose any cost sharing requirements, such as copayment amounts, coinsurance amounts, or deductible amounts, on the preventive care services required under §C of this regulation.

(2) If a carrier’s plan permits individuals covered under the plan to receive services from nonparticipating providers, the carrier may impose a carrier’s coinsurance percentage of 60 percent of allowable charges.

(3) If a new recommendation or guideline described in §C of this regulation is issued after the effective date of the plan, the new recommendation or guideline shall apply the first plan year that begins on the date that is 1 year after the date the recommendation or guideline is issued.