What is considered “Preventive Services” that are covered at 100% under Health Care Reform?

 Now is the time to stay healthy with “FREE” preventive care services!

Preventive health care–including annual physical exams, screenings, and immunizations–is essential to good health. Yet many Americans don’t receive the regular preventive care they need, despite the fact that chronic diseases, which are responsible for 7 of 10 deaths among Americans each year and account for 75% of the country’s health care spending–are often preventable.

Why do so few Americans get the preventive care they need? Often, the reason is cost.

The Affordable Care Act (health care reform) attempts to address this problem by requiring all new group and individual health insurance plans as of September 23, 2010 to pay 100% of the costs for preventive care services ranked A and B by the U.S. Preventive Services Task Force (USPSTF) .

If your health plan qualifies, you can take advantage of a wide range of preventive care services to help you avoid illness and improve your health–at no cost to you, so long as you receive these services from a health care provider within your health plan’s network of doctors and hospitals.

You won’t have to pay a copayment at the office visit, and not a penny toward coinsurance or your deductible. Doctors and health care facilities continue to charge for these services. But now it’s the health insurance companies that pay the costs. Essentially, preventive care becomes ‘free’ for the policyholder, greatly increasing the incentive to take advantage of these services. The following lists outline the preventive care services covered by these rules for adults, women, and children.

Adults

Covered preventive services for adults include:

  • Abdominal aortic aneurysm
  • A one–time screening for men of specified ages who have ever smoked
  • Colorectal cancer screening
  • Depression screening for adults
  • Type 2 diabetes screening
  • Diet counseling for adults at higher risk for chronic disease 
  • HIV screening for all adults at higher risk  
  • Immunization vaccines for adults (recommendations vary):
    • Hepatitis A
    • Hepatitis B
    • Herpes zoster
    • Human papillomavirus
    • Influenza (flu shot)
    • Measles, mumps, rubella
    • Meningococcal
    • Pneumococcal
    • Tetanus, diphtheria, pertussis
    • Varicella
  • Obesity screening and counseling for all adults
  • Sexually transmitted infection (STI) prevention counseling for adults at higher risk 
  • Tobacco use screening for all adults and cessation interventions for tobacco users 
  • Syphilis screening for all adults at higher risk

Women

Women Covered preventive care services for women, including pregnant women, include:

  • Anemia screening on a routine basis for pregnant women
  • Bacteriuria urinary tract or other infection screening for pregnant women
  • BRCA (breast cancer gene) counseling about genetic testing for women at higher risk
  • Breast cancer mammography screenings every one to two years for women over 40
  • Breast cancer chemoprevention counseling for women at higher risk
  • Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women*
  • Cervical cancer screening for sexually active women
  • Chlamydia infection screening for younger women and other women at higher risk
  • Contraception : Food and Drug Administration–approved contraceptive methods, sterilization procedures, and patient education and counseling, not including abortifacient drugs*
  • Domestic and interpersonal violence screening and counseling for all women*
  • Folic acid supplements for women who may become pregnant
  • Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes*
  • Gonorrhea screening for all women at higher risk
  • Hepatitis B screening for pregnant women at their first prenatal visit
  • Human immunodeficiency virus (HIV) screening and counseling for sexually active women*
  • Human papillomavirus (HPV) DNA test : High–risk HPV DNA testing every three years for women age 30 or older* with normal cytology results
  • Osteoporosis screening for women over 60, depending on risk factors
  • Rh blood incompatibility screening for all pregnant women and follow–up testing for women at higher risk
  • Tobacco use screening and interventions for all women, and expanded counseling for pregnant tobacco users
  • Sexually transmitted infections (STI) counseling for sexually active women*
  • Syphilis screening for all pregnant women or other women at increased risk
  • Well–woman visits to obtain recommended preventive services for women under 65*

Note: Services marked with an asterisk (*) must be covered with no cost–sharing in plan years starting on or after August 1, 2012.

Children
Covered preventive care services for children include:

  • Alcohol and drug use assessments for adolescents 
  • Autism screening for children at 18 and 24 months 
  • Behavioral assessments for children of all ages 
  • Blood pressure screening for children 
  • Cervical dysplasia screening for sexually active females 
  • Congenital hypothyroidism screening for newborns 
  • Depression screening for adolescents
  • Developmental screening for children under age 3, and surveillance throughout childhood 
  • Dyslipidemia screening for children at higher risk of lipid disorders 
  • Fluoride chemoprevention supplements for children without fluoride in their water source 
  • Gonorrhea preventive medication for the eyes of all newborns 
  • Hearing screening for all newborns 
  • Height, weight, and body mass index measurements for children 
  • Hematocrit or hemoglobin screening for children 
  • Hemoglobinopathies or sickle cell screening for newborns 
  • HIV screening for adolescents at higher risk 
  • Immunization vaccines for children from birth to age 18 (recommendations vary): o
    • Diphtheria, tetanus, pertussis
    • Haemophilus influenzae type B
    • Hepatitis A
    • Hepatitis B
    • Human papillomavirus
    • Inactivated poliovirus
    • Influenza (flu shot)
    • Measles, mumps, rubella
    • Meningococcal
    • Pneumococcal
    • Rotavirus
    • Varicella 
  • Iron supplements for children ages 6 to 12 months at risk for anemia
  • Lead screening for children at risk of exposure
  • Medical history for all children throughout development
  • Obesity screening and counseling
  • Oral health risk assessment for young children
  • Phenylketonuria (PKU) screening for this genetic disorder in newborns
  • Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
  • Tuberculin testing for children at higher risk of tuberculosis
  • Vision screening for all children

It’s important to keep in mind that while the health plan cannot charge you a copayment, deductible, or coinsurance when the primary purpose of the office visit is the recommended preventive care service and the service is NOT billed separately from the office visit, you may be required to share some of the costs if the preventive service is not the primary purpose of the office visit. And remember, preventive services are covered at 100% only when received from health care providers within the health plan’s network. For the most up–to–date list of covered preventive care services, please visit http://www.uspreventiveservicestaskforce.org

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UHC provides Rx cost calculator

With health care costs continuing to hurt our pocketbook, many consumers have moved to high deductible plans.  HSA qualified plans require that the insured (not the insurance company) is responsible to pay prescription costs toward that high deductible.  Most of us are unaware of our prescription costs, but with the new HSA plans, we can help ourselves save money if we knew the cost of our prescription options.

UHC has a great online tool to help us identify prescription costs.  You can access it here.  This is only an example of costs through Medco, so your costs will differ depending on your insurance plan and pharmacy.  It also shows you the cost for mail order compared to filling your prescription at a retail pharmacy.

I looked up 80mg tabs of Zocor, a common cholesterol drug.  A 30 day supply from a retail outlet showed $163.59, whereas the generic Simvastatin costs only $12.05.  Yikes, the brand name was 1300% higher!

Why not check your costs.

 

 

Anthem Revised Rules Regarding Lipitor

 Anthem Blue Cross of California has recently announced that all members with prescriptions for Lipitor will need to have their prescriptions pre-authorized effective April 1, 2012 

This change is due to the addition of atorvastatin, a new generic for the brand name Lipitor, on their covered drug list.

This change impacts all of the commercial and individual business in California and New York. Medicare Part D and state-sponsored business are not impacted.

Employers, Do You Know The Rules??

 As an ERISA Plan Administrator (most private sector employers fall under ERISA law), you have the responsibility to comply with Federal Laws that govern your plan.  No matter who else you may hire to administer your plan, your Company is solely responsible to make sure things are done correctly.  As an employer offering benefits to your employees, there are many rules that you must comply with regarding the administration of employee benefit plans.  Below are some of the rules you must be careful to comply with in under law:

  •  Make sure you define – in writing in an employee handbook- the definitions of eligible employees and dependents.  For example, do you only offer benefits to full time employees over 40 hours per week?  However you define eligibles, make sure you are consistent in benefits that you offer and monitor to make sure you remain consistent.   Make sure you also define leave policies and waiting periods as well.
  • Make sure your plan complies with benefits mandate by state law and health care reforms.
  • Benefit and eligibility information must be provided to eligible participants or be made available at their request.
  • Make sure you file all necessary plan documents, such as 5500 reports.

Please remember that failure to follow the rules can be costly.  For example, the fine for failure to file the 5500 report is $1,000 PER DAY.

If we may be of any assistance to you or can help you organize a compliance process, please contact Gary Whiddon at (888)474-6627.

 

Aetna – CA Small Group New Rates & Plan Changes effective April 1, 2012

Aetna will introduce six new plans for Small Group clients in California. The new portfolio includes two HMOs and four Managed Choice® (MC) plans. All are effective April 1, 2012.

All of these new plans build on rates and benefits that brokers and plan sponsors have requested. 

More on the new plans: 

  • The new plans were designed to help employers and employees save on health care costs while getting a plan that meets their needs.
  • All of the HMO and MC/PPO plans alongside each other.
  • Plan sponsors can set their contribution rates on the lowest priced plan, and their employees can “buy up” to different plans if they wish to do so.

Just look at some of the key benefits these plans offer your employees:

IMPORTANT PLAN CHANGES: In addition to introducing new plans, some changes were made to existing plans. Look at the Renewal guide for details about the changes to specific plans. Please note: There are changes to every plan — so it is important for you to review the changes. You can also view the new Plan Guide here

Other plan highlights include:

  • Vision benefit now included with all plans — One exam every 24 months. Includes refractive testing. 
  • Wellness/health incentive benefit — Employees and their spouses/domestic partners can earn up to $100 for completing a wellness program through simple steps.
  • Brokers and employees can complete adds and terms online.
  • As of March 2012, an employer can obtain a new employee’s member ID right in the on-line enrollment tool as soon as the enrollment has been processed.