Patient Protection and Affordable Care Act (PPACA): Rules for Coverage of Preventive Health Services without Cost-Sharing

August 18, 2011

The Departments of Health and Human Services, Labor and the Treasury jointly released interim final regulations related to coverage of preventive services under the Patient Protection and Affordable Care Act (PPACA).

Important Message about Cigna’s Preventive Health Services

The following outlines the procedures that should be followed when preventive care services are the primary purpose of your patient’s visit.

Determine if your patient’s Cigna administered plan covers preventive care at 100 percent:

• Visit www.cignaforhcp.com to verify benefit and eligibility information, or call 1.800.88Cigna (882.4462).
• For patients with a GWH-Cigna or Great-West Healthcare ID card, visit http://www.greatwesthealthcare.com, or call 1.800.663.8081.

Submit preventive care services claims with the ICD-9 diagnosis code in the primary (first) diagnosis code on the claim form:

• If claims for preventive care services are submitted with diagnosis codes that represent treatment of illness or injury as the primary diagnosis on the claim, the service will not be identified as preventive care and the claim will not be processed under the enhanced preventive care coverage.
• If claims for preventive care services are submitted with diagnosis codes that represent treatment of illness or injury as the primary diagnosis on the claim, the service will not be identified as preventive care and the claim will not be processed under the enhanced preventive care coverage.

Non-preventive care services/procedure codes will be covered as applicable with normal cost share.

General Highlights of New Regulations

These regulations apply to group health plans (including self-insured plans) and health insurance coverage issued in the group and individual markets.

Plans must cover, without a copay, coinsurance or deductible, certain preventive services that have clear health benefits (as shown by strong scientific evidence).

• The cost-sharing requirement applies to in-network coverage only for network plans that provide both in- and out-of-network coverage. However, these types of plans are not required to provide coverage for recommended preventive services delivered by an out-of-network healthcare professional, or may impose cost-sharing for recommended preventive services delivered by an out-of-network health care professional.
• Plans without a network, e.g., indemnity plans, must cover preventive care at no cost-share.

Services designated as preventive care include periodic well visits, routine immunizations and routine screenings for symptom-free or disease-free individuals.

Preventive care services also generally include immunization and screening services for symptom-free or disease-free individuals at increased risk for a particular disease.

Plans that cover preventive services in addition to those required may apply cost-sharing requirements for the additional services.

These regulations are effective for plan years beginning on or after September 23, 2010.

General List of Services to be Offered Without Copay, Coinsurance or Deductible

Evidence-based preventive services:

This list of items is from the current recommendations of the United States Preventive Services Task Force. This broad list generally includes:

• Breast cancer and cervical cancer screenings
• Colon cancer screenings
• Screening for iron deficiency anemia in pregnancy
• Screenings for diabetes, high cholesterol and high blood pressure

Routine vaccinations:
A list of immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention are included in the rule. They are considered routine for use with children, adolescents, and adults and range from childhood immunizations to periodic tetanus shots for adults.

Prevention for children:
The rule 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. Services include regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, and screening and counseling to address obesity.

Prevention for women:
The regulation mandates certain preventive care measures for women. These recommendations will be in place until new requirements for prevention for women are issued by the United States Preventive Services Task Force or appear in comprehensive guidelines supported by the Health Resources and Services Administration. The new requirements are expected to be released by August 1, 2011.

Breast cancer screening:
All women age 40 and over should have an annual mammogram.

Medications:
Cigna has identified four prescriptions or over-the-counter (OTC) medications impacted by the regulations. These medications and OTCs will be administered under our Pharmacy benefits for your patients that receive their Pharmacy benefits through Cigna, and will require a prescription:

Note: Ocular topical medication for newborns is also referenced in the regulations; however, this medication is typically administered shortly after birth and covered under the medical benefit.

For additional information, including a full list of covered preventive services issued as part of the Interim Final Regulations, visit these websites: http://www.healthcare.gov/center/regulations/prevention/taskforce.html, or http://www.healthcare.gov/center/regulations/prevention/recommendations.html.

Cigna expects ongoing clarification of the specific requirements of the PPACA legislation, and our policies and coverage standards will evolve accordingly. To get the most current information visit www.InformedonReform.com or www.Cigna.com and click ‘Informed on Reform’.