ACA Mandates First Dollar Coverage for Preventive Services

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1 I N F O R M A T I O N U P D A T E May 2013 ACA Mandates First Dollar Coverage for Preventive Services The Affordable Care Act (ACA) mandates that, effective for Plan Years beginning on or after Sept. 23, 2010, certain group and individual health plans must provide coverage for preventive services with no member cost share when provided by in-network clinicians. Wellmark will provide first dollar coverage for preventive services when they are provided by in-network providers (benefit coverage and cost sharing will apply for out-of-network services as specified in the coverage document). Health plans may apply cost sharing to out-of-network preventive care, and they may utilize reasonable medical management techniques to help control costs and promote efficient delivery of care. This coverage is applicable to certain group and individual health plans, as indicated below, and was effective for plan years beginning on or after Sept. 23, 2010, Plans that are required to provide preventive coverage with no member cost share All non-grandfathered fully insured and self-funded plans, including those that did not currently cover preventive services. Plans that are NOT currently required to provide preventive coverage Grandfathered group and individual plans (coverage not required until 2014) Grandfathered plans that already provide preventive coverage are allowed to maintain member cost share Effective for plan years on or after Aug. 1, 2012 or Jan. 1, 2013 for calendar year plans, additional women s preventive services are to be covered without cost sharing requirements when performed by an in-network provider. The additional services are based on scientific research and recommended by the Independent Institute of Medicine (IOM). How Preventive Care Services Are Defined: Preventive services are defined under the ACA as those immunizations, screenings, and other services that are listed as recommended by the United States Preventive Services Task Force (USPSTF),* the Health Resources Services Administration (HRSA), and the federal Centers for Disease Control (CDC).* Important Note: The services identified are recommendations by ACA to clinicians, not mandated services. It is up to the clinician to decide which services to provide. Preventive Health Services List Below is a representative list of the preventive health services that are required to be covered, with no member cost-share, by non-grandfathered plans effective with plan years beginning on or after September 23, This list is based on information available online at the federal government s Health Care Reform Site: HCR Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association

2 Preventive Health Services Covered Under the Affordable Care Act (ACA) This list is not all-inclusive and benefits are not guaranteed. Please see the Notes section below. MEN & WOMEN Adult immunizations (provided in a physician's office or at a pharmacy) includes: Hepatitis A; Hepatitis B; Herpes Zoster; Human Papillomavirus; Influenza (Flu Shot); Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Tetanus, Diptheria, Pertussis; Varicella Aspirin for the prevention of cardiovascular disease in men and women of certain ages (prescription required for full coverage) Depression screening Diet & behavioral counseling in primary care to promote a healthy diet (for adults who are at risk for chronic disease) Alcohol misuse screening & behavioral counseling interventions Colorectal cancer screening - colonoscopy, sigmoidoscopy, laboratory & pathology for adults over 50 Diabetes screening (Type 2 Diabetes for adults with high blood pressure) High blood pressure screening HIV screening for all adults at higher risk Lipid screening (Cholesterol screening) for adults of certain ages or those at higher risk Obesity screening and counseling for those at risk populations Sexually transmitted infections & counseling for at risk populations Syphilis infection screening for at risk populations Tobacco use screening and counseling and cessation interventions MEN ONLY Abdominal Aortic Aneurysm one-time screening aged who have ever smoked ALL WOMEN ONLY Bone density (osteoporosis screening) Breast cancer screening (including mammography) every 1-2 years for women over age 40 Cervical cancer screening Genetic counseling and evaluation for the BRCA breast cancer gene for at-risk women. Breast Cancer Chemoprevention counseling for those who are at higher risk Chlamydia screening for all sexually active non-pregnant women aged 24 and younger, and older non-pregnant women at higher risk Contraception and contraceptive counseling: this applies to FDA-approved contraceptive methods meant for direct use by a women* Gonorrhea screening for post-menopausal women Domestic violence screening and counseling: annual screening and counseling for interpersonal and domestic violence available to women* Human Papillomavirus (HPV) DNA test: women 30 and older may receive high-risk HPV screening every three years, regardless of Pap test results* Osteoporosis screening for post-menopausal women Syphilis infection screening for those at higher risk Sexually Transmitted Infections (STI) and HIV screening and counseling: annual counseling on HIV and STIs for sexually active women* Well-woman visits, including annual well-woman preventive care office visits* 2

3 For Pregnant Women Asymptomatic bacteriuria screening (UTI) Chlamydia screening for all pregnant women aged 24 and younger, and for older pregnant women at higher risk Gestational Diabetes screening pregnant women at high risk of developing Gestational Diabetes may be screened between weeks of gestation* Hepatitis B virus infection screening at first prenatal visit Primary care Interventions to promote breastfeeding Sexually transmitted infections counseling Syphilis infection screening for those at higher risk FOR NEWBORNS/CHILDREN Congenital hypothyroidism screening for newborns Dental caries screening for preschool children Fluoride treatment for children (prescription required for full coverage) Major depressive disorder screening for children and adolescents Gonorrhea, prophylactic medication for newborns (prescription required for full coverage) Hearing screening for newborns Autism screening for children at 18 and 24 months Behavioral assessments for children of all ages Cervical dysplasia screening for sexually active females Dyslipidemia screening for those at higher risk of lipid disorders Height, Weight and Body Mass Index measurements Lead screening for children at risk to exposure Breast feeding support, supplies and counseling: counseling may be provided during pregnancy and/or in the postpartum period. Manual breast pumps are covered with no cost share under certain conditions* Daily folic acid supplements for women capable of becoming pregnant (prescription required for full coverage) Gonorrhea screening for those who are at higher risk Iron deficiency anemia screening Rh (D) blood typing and antibody testing for incompatibility screening STD testing based on risk (other than Chlamydia & HIV) Immunizations (provided in a physician's office or at a pharmacy), includes: Diphtheria, Tetanus, Pertussis; Haemophilus influenza type b; Hepatitis B; Human Papillomavirus; Inactive Poliovirus; Influenza (Flu Shot); Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Rotavirus; Varicella Iron supplements for at risk infants 6-12 months (prescription required for full coverage) Phenylketonuria (PKU) screening for newborns Screening and interventions for childhood obesity Sickle Cell disease screening for newborns Tuberculin testing for children at higher risk of Tuberculosis Visual impairment screening Blood pressure screening Developmental screening for children under age 3, and surveillance throughout childhood Hematocrit or Hemoglobin screening HIV screening for adolescents at higher risk Medical History for all children throughout development Oral health risk assessment for young children 10 or under Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk 3

4 Exceptions for Religious Organizations: Religious organizations that meet specific criteria may qualify to choose not to cover contraception. Proposed regulations state that in order to qualify for this exemption, organizations must: Oppose providing coverage for some or all of the contraceptive services required to be covered under section 2713 or the PHS Act on account of religious objections The organization is organized and operates as a nonprofit entity The organization holds itself out as a religious organization The organization self-certifies that it satisfies the first three criteria Additional Information: Depending on the benefit plan, many of the recommended services are already covered under existing Wellmark plans when claims are coded as preventive. For additional information, visit the federal Health Care Reform (link above) or the USPSTF website: Members of Wellmark Health Plan of Iowa will still be required to receive most preventive services from their designated primary care practitioners. Prior authorization policies for selected services will remain in place. Claims for covered immunizations, whether submitted and paid under a Blue Rx plan when received at pharmacies that contract for immunizations, or under a health plan, when received in a doctor office setting, will be paid with no member cost share when they are provided by in-network providers. Periodic physicals and OB/GYN exams received from in-network clinicians will be provided with no member cost share. Per the USPSTF and HRSA guidelines, some screenings and services may be recommended based on day or visit limits, or certain time intervals. Notes: The list above is not all-inclusive and benefits are not guaranteed. Age and gender limitations may apply. For more information on required preventive services, go to the federal government s Health Care Reform site Only preventive services received from a network provider will be covered at 100% with no member cost share. Wellmark will apply its standard medical management policies and procedures, as specifically mentioned and allowed under the Affordable Care Act. The list of preventive services included in the law is recommended by the USPSTF, the HRSA, and the CDC**. Please note that there are differences between preventive screenings, exams and services vs. treatment for specific diseases and illnesses. The following is a link to the recommended immunizations schedules: *The federal Affordable Care Act (ACA) requires that non-grandfathered group health plans and individual policies provide benefits for certain preventive health services without the imposition of cost sharing. These preventive care and screening provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA) that were issued in Aug. 1, 2011 and are effective for plan/policy years on or after Aug. 1, Consistent with the HRSA, women will have access to these preventive services with no cost share when provided by in-network providers. ** Section 2713 of the ACA references recommendations by the USPSTF, the HRSA, and the CDC. The United States Preventive Services Task Force is a federal agency that makes its recommendations on the basis of explicit criteria. Recommendations issued by the USPSTF are intended for use in the primary care setting. The Task Force recommendation statements present health care providers with information about the evidence behind each recommendation, allowing clinicians to make informed decisions about implementation. Wellmark consults with the Task Force regularly to determine how preventive services may be covered. The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, (HHS) is the primary Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable. The Centers for Disease Control and Prevention: one of the major operating components of the Department of Health and Human Services, CDC s Mission is to collaborate to create the expertise, information, and tools that people and communities need to protect their health through health promotion, prevention of disease, injury and disability, and preparedness for new health threats. 4

5 Wellmark is not providing any legal advice with regard to compliance with the requirements of the Affordable Care Act (ACA) or the Mental Health Parity Addiction Equity Act (MHPAEA). Regulations and guidance on specific provisions of the ACA and MHPAEA have been and will continue to be provided by the U.S. Department of Health and Human Services (HHS) and/or other agencies. The information provided reflects Wellmark's understanding of the most current information and is subject to change without further notice. Please note that plan benefits, rates, renewal rate adjustments, and rating impact calculations are subject to change and may be revised during a plan s rating period based on guidance and regulations issued by HHS or other agencies. Wellmark makes no representation as to the impact of plan changes on a plan's grandfathered status or interpretation or implementation of any other provisions of ACA. Any questions about Wellmark's approach to the ACA of MHPAEA may be referred to your Wellmark account representative. Wellmark will not determine whether coverage is discriminatory or otherwise in violation of Internal Revenue Code Section 105(h). Wellmark also will not provide any testing for compliance with Internal Revenue Code Section 105(h). Wellmark will not be held liable for any penalties or other losses resulting from any employer offering coverage in violation of section 105(h). Wellmark will not determine whether any change in an Employer Administered Funding Arrangement affects a health plan s grandfathered health plan status under ACA or otherwise complies with ACA. Wellmark will not be held liable for any penalties or other losses resulting from any Employer Administered Funding Arrangement. For purposes of this paragraph, an Employer Administered Funding Arrangement is an arrangement administered by an employer in which the employer contributes toward the member s share of benefit costs (such as the member s deductible, coinsurance, or copayments) in the absence of which the member would be financially responsible. An Employer Administered Funding Arrangement does not include the employer s contribution to health insurance premiums or rates. 5

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