A Texas enrollee in a non-grandfathered Marketplace plan receives a recommended preventive service from an in-network provider. How must the plan treat the cost of that service?
Select an option to reveal the answer and the full 3-part explanation — free, no signup.
Answer & full 3-part explanation (select an option above, or peek)
Why D is correct
Under ACA Section 1302 and the rules implementing it, a non-grandfathered plan must cover recommended preventive services, meaning items rated by the U.S. Preventive Services Task Force, immunizations recommended by the immunization advisory committee, and preventive care for women and children under the federal guidelines, with no cost sharing when an in-network provider delivers them. Charging a deductible or copayment for such a service is a violation, and the requirement does not apply to grandfathered plans, which is why an agent should confirm the plan's grandfathered status before promising free preventive care.
Why the other options are wrong
- A) Applying the deductible to a recommended in-network preventive service is prohibited for non-grandfathered plans.
- B) Preventive and wellness services and chronic disease management are among the essential health benefit categories, so prevention is not outside the benefit definition.
- C) The no-cost-sharing rule does not wait until the out-of-pocket maximum is met; it applies from the first service.
Memory hook
In-network prevention, zero at the desk.