Preventive Care Services
© Blue Cross and Blue Shield of Montana
Current Effective Date:
February 15, 2014
Original Effective Date:
October 01, 2010
January 15, 2014
February 4, 2011; March 21, 2011; September 23, 2013; January 15, 2014
Preventive care or preventive medicine refers to measures or services taken to promote helah and early detection/prevention of disease(s) and injuries rather than treating them and/or curing them.
Preventive care may include examinations and screening tests tailored to an individual’s age, health, and family history.
What is the Patient Protection and Affordable Care Act?
The Patient Protection and Affordable Care Act (PPACA), also known as Affordable Care Act (ACA) or Health Care Reform, is a U.S. Federal Statute that was signed into law on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010, it represents significant change in government regulations of the U.S. healthcare system. The law includes a large number of health-related provisions that would become effective over the four years since being signed into law, including preventive care services. Effective by January 1, 2018, all existing select health insurance plans must cover approved preventive care and checkups without cost-sharing, such as co-payments, co-insurance, or deductibles. Grandfathered plans are exempt from this requirement.
What has been the history or timeline for Health Care Reform?
The current Health Care Reform or ACA arose from the 1930’s to the present as a method of providing health care to more and more individuals who could not afford medical care.
- 1965 – President Lyndon Johnson enacted legislation that introduced Medicare, covering both hospital and general medical insurance for senior citizens paid for by a Federal employment tax over the working life of the retiree; and, Medicaid permitted the Federal government to partially fund a program for the poor, with the program managed and co-financed by the individual states.
- 1985 – The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) amended the Employee Retirement Income Security Act of 1974 (ERISA) to give some employees the ability to continue health insurance coverage after leaving employment.
- 1993 – Increasing concerns over Health Care Reform had been brought forward for debate and resolution by President Bill Clinton. However, the 1993 Health Care Plan was proposed and subsequently never enacted into law.
- 1996 – The Health Insurance Portability and Accountability Act (HIPAA) was enacted by President Bill Clinton. Title I protects health insurance coverage for workers and their families when they change or lose their jobs. Title II requires establishment of national standards for electronic health care transactions and national identifiers for providers, health insurance plans, and employers. Title II includes the definitions, procedures, and guidelines for maintaining privacy and security of individually identifiable health care information, as well as creating programs to control fraud and abuse within the health care system.
- 1997 – The State Children's Health Insurance Program, or SCHIP, was established by the federal government in 1997 to provide health insurance to children in families at or below 200 percent of the federal poverty line.
- 2010 – The PPACA or ACA, as described above, was enacted by President Barack Obama. By January 1, 2020, all facets of ACA shall have been phased in and operational.
Glossary of Terms
- Cost Sharing – The amount of money paid by the patient for health services, such as co-insurance, deductibles, co-payments.
- Evidence-Based Medicine – Is a term applied to medical practices that have been thoroughly evaluated by peer-reviewed journals, and have been deemed safe and effective by the scientific community. Ratings or Grading may have been assigned to the medical practice being reviewed.
- Grandfathering – Allows health plans to remain as is and not be required to implement certain changes or aspects of ACA’s new rules and protections. These plans were in existence prior to March 23, 2010. Under this provision, health plans are allowed to make routine changes to their policies, such as cost-adjustments, adding new benefits, some adjustments to existing benefits, voluntarily adopting new consumer protections, or making changes to comply with Federal or State laws.
- Network (Preferred) Provider – A provider, such as a hospital or doctor, who has contracted with the health plan
- Non-Grandfathering – Health plan has reduced or changed the individual’s benefits or increased the cost to the consumer.
- Out-of-Network (Non-Preferred) Provider – A provider, such as a hospital or doctor, who has not contracted with the health plan.
- Out-of-Pocket Costs – Health care costs that are not covered by the health care plan, such as deductibles, co-payments, and deductibles. Out-of-Pocket costs do not include insurance premiums.
- Prevention for Adults – Includes certain preventive care measures for adults as recommended by the Health Resource and Services Administration with the U.S. Preventive Services Task Force (USPSTF), such as abdominal aortic aneurysm screening for men, depression screening, sexually transmitted infections (STI) prevention counseling, and many other screenings, services, and/or counseling on a variety of subjects.
- Prevention for Children – Includes preventive care guidelines for children from birth to age 21 developed by the Health Resources and Services Administration with the American Academy of Pediatrics (AAP). These services include regular pediatrician (primary care provider) visits, developmental assessments, immunizations, and screening and counseling to address obesity.
- Prevention for Women (and Pregnant Women) – Includes certain preventive care measures for women as recommended by the Health Resource and Services Administration with the U.S. Preventive Services Task Force (USPSTF), such as mammograms, screening for cervical cancer, and many other screenings, services, and/or counseling on a variety of subjects.
- Routine Immunizations – Vaccines that are considered routine for use with children, adolescents, and adults, and range from childhood immunizations to periodic tetanus shots for adults. The immunizations are recommended by the American Academy of Family Practice (AAFP), American Academy of Pediatrics (AAP), or Advisory Committee on Immunization Practices (ACIP)-(part of the Center for Disease Control and Prevention - the CDC) Refer to Medical Policy, ADM1001.025, Recommended Immunization Schedule for Children and Adults for more information.
- U.S. Preventive Services Task Force (USPSTR or Task Force) – Is an independent group of national experts in prevention and evidence-based medicine that works to improve the health of all Americans by making evidence-based recommendations about clinical preventive services such as screenings, counseling services, or preventive medications. The USPSTF is made up of 16 volunteer members who come from the fields of preventive medicine and primary care, including internal medicine, family medicine, pediatrics, behavioral health, obstetrics or gynecology, and nursing. All members volunteer their time to serve on the USPSTF, and most are practicing clinicians.
Each benefit plan, summary plan description or contract defines which services are covered, which services are excluded, and which services are subject to dollar caps or other limitations, conditions or exclusions. Members and their providers have the responsibility for consulting the member's benefit plan, summary plan description or contract to determine if there are any exclusions or other benefit limitations applicable to this service or supply. If there is a discrepancy between a Medical Policy and a member's benefit plan, summary plan description or contract, the benefit plan, summary plan description or contract will govern.
Disclaimer for coding information on Medical Policies
Procedure and diagnosis codes on Medical Policy documents are included only as a general reference tool for each policy. They may not be all-inclusive.
The presence or absence of procedure, service, supply, device or diagnosis codes in a Medical Policy document has no relevance for determination of benefit coverage for members or reimbursement for providers. Only the written coverage position in a medical policy should be used for such determinations.
Benefit coverage determinations based on written Medical Policy coverage positions must include review of the member’s benefit contract or Summary Plan Description (SPD) for defined coverage vs. non-coverage, benefit exclusions, and benefit limitations such as dollar or duration caps.
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- Affordable Health Care For America (2010 March 18). Prepared by the House Committees on Ways and Means, Energy and Commerce, and Education and Labor. Available at http://housedocs.house.gov (accessed on 2013 February 22).
- Guide to Clinical Preventive Services, 2012 – Recommendations of the U.S. Preventive Services Task Force. Prepared by the Agency for HealthCare Research and Quality from Recommendations by the U.S. Preventive Services Task Force. Available at http://www.ahrq.gov (accessed on 2013 February 22).
- USPSTF A and B Recommendations (2013 January). Prepared by the U.S. Preventive Services Task Force. Available at http://www.uspreventiveservicestaskforce.org (accessed on 2013 February 22).
- The Affordable Care Act and Wellness Programs (2013 February 25). Prepared by U.S. Federal Government. Available at http://www.healthcare.gov (accessed on 2013 February 25).
- The Guide to Community Preventive Services – The Community Guide, What Works to Promote Health 2013. Prepared by the Community Services Task Force of the Centers for Disease Control and Prevention. Available at http://www.cdc.gov (accessed on 2013 February 25).
|February 4, 2011
||Added the following to the description: "Preventive tests, as outlined below, must be ordered by the member’s treating health care provider, either as a component of a health maintenance evaluation, or as an evaluation of a medical condition for benefits to apply."|
|March 21, 2011
||Revised to state: "BCBSMT is currently not reviewing claims to apply benefits based on this recommendation."|
||Policy formatting and language revised.|
||Document update based upon the U.S. Preventive Service Task Force A/B Recommendations for the U.S. Federal Affordable Care Act. The following was changed: 1.) Skin cancer behavioral counseling was added; 2.) Intimate partner violence screening was changed from domestic violence counseling; 3.) Prevention of falls for adults age 65 and older was added; 4.) Vitamin D supplementation was added; 4.) Gender and age groups added for aspirin recommendation to prevent cardiovascular disease; and 5.) Hepatitis C screening was added. CPT/HCPCS codes updated.|