Can you name all the preventive health services that commercial health plans must cover under the Affordable Care Act? See the links below for services for adults, women, and children.
When insured patients receive these services in network, they do not have to pay a copayment or coinsurance, even if they haven't met their deductible. This applies to patients with health insurance plans that began on or after Sept. 23, 2010. (A few of the preventive services for women apply only to plans starting on or after Aug. 1, 2012, as noted in the list at the link below). "Grandfathered" health plans are exempt from the requirement to cover these services.
Here are links to preventive services guides from the major payers:
(As a reminder, Medicare also covers preventive health services and provides specific information on how to bill for those services. See the Medicare Learning Network Preventive Services page.)
There are circumstances, however, under which insurers may charge copayments and use other forms of cost-sharing when paying for preventive services. These include:
- If the office visit and the preventive service are billed separately, the insurer may still charge cost-sharing for the office visit itself.
- If the primary reason for the visit is not the preventive service, patients may have to pay for the office visit.
- If an out-of-network physician performs the service when an in-network physician is available to do so, insurers may charge patients for the office visit and the preventive service. However, if the patient chooses an out-of network physician because no in-network physician able to provide the service is available, then the insurer cannot impose cost-sharing.
- If a treatment is given as the result of a recommended preventive service, but is not the recommended preventive service itself, the insurer may change cost-sharing.
Physicians can use modifier 33 to identify that a service was preventive under the law and patient cost-sharing does not apply. See more information from the AAPC and from the Kaiser Family Foundation.
The Centers for Medicare & Medicaid Services' Center for Consumer Information and Insurance Oversight (CCIIO) published frequently asked questions about preventive services. Here are highlights:
Q. Some preventive services, including counseling and immunizations, apply to certain populations identified as high-risk, as recommended by the U.S. Preventive Services Task Force or the Advisory Committee on Immunization Practices. How will a health plan identify who is a high-risk and thus determine when to cover a service without cost-sharing?
A. CCIIO says the government has clarified that it is up to the physician or health care provider to identify high-risk patients who are subject to the recommendations and therefore eligible to receive a specific preventive item or service identified through the ACA for those at high risk. However, health plans can impose limits on the number of visits or tests, cover only generics or selected brands of pharmaceuticals, or require prior authorization to acquire a preferred brand drug.
Q. Preventive services for women are based on Health Resources and Services Administration (HRSA)-supported guidelines. Do the recommendations in the HRSA guidelines promote multiple visits for separate services?
A. No. Nothing in the law or the regulations requires that each service be provided in a separate visit. For example, HIV screening and counseling, and sexually transmitted infections counseling could occur as part of a single well-woman visit.
Q. What do physicians need to know to conduct screening and counseling for interpersonal and domestic violence?
A. Screening may consist of a few, brief, open-ended questions, perhaps with the use of brochures, forms, or other assessment tools including chart prompts. Counseling provides basic information, including how a patient's health concerns may relate to violence and referrals to local domestic violence support agencies when patients disclose abuse.
If you have questions about billing and coding or payer policies, contact a TMA reimbursement specialist at firstname.lastname@example.org, or call the TMA Knowledge Center at (800) 880-7955.
Updated Sept. 1, 2016
Published April 13, 2015
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