THE PREVENTIVE CARE REGULATIONS

Transcription

1 THE PREVENTIVE CRE REGULTIONS M& Comments: The following materials are referenced in our ectionlert dated ugust 6, 2010 and provide the reader with more detailed information on the specific requirements of the Interim Final Regulations on preventive care as published in the Federal Register. ackground:, whose origins date to 1984, is an independent panel of non- Federal experts in prevention and evidence-based medicine and is composed of primary care providers (such as internists, pediatricians, family physicians, gynecologists/obstetricians, nurses, and health behavior specialists). The USPSTF conducts scientific evidence reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and develops recommendations for primary care clinicians and health systems. The Effective dates in the following chart are the dates the Task Force promulgated the listed recommendations. The Task Force recommendations are assigned a letter-grade from to D based on the probable magnitude and the certainty of benefit from the recommendations. The rationale for each letter-grade is illustrated in the following table. Certainty of Net enefit U.S. Preventive Services Task Force Recommendation Grid* Magnitude of Net enefit Substantial Moderate Small Zero/ Negative High C D Moderate C D Low Insufficient The ffordable Care ct will require insurance companies to cover any and all preventive services that receive an "" or "" grade, but permit them to use discretion on preventive services that receive a lower grade. CTEGORY ONE: U.S. PREVENTIVE SERVICES TSK FORCE RECOMENDTIONS Grade and Recommendations of the United States Preventive Services Task Force Topic Text Grade Effective abdominal aortic aneurysm Screening and counseling to reduce alcohol misuse The USPSTF recommends one-time screening for abdominal aortic aneurysm () by ultrasonography in men aged 65 to 75 who have ever smoked. recommends screening and behavioral counseling interventions to reduce alcohol misuse (go to Clinical Considerations) by adults, including pregnant women, in primary care settings. Feb 28, 2005 pril 30, 2004 Mahoney&ssociates Creative Compensation & enefit Solutions

2 spirin to prevent CVD: men The USPSTF recommends the use of aspirin for men age 45 to 79 years when the potential benefit due to a reduction in myocardial infarctions outweighs the potential harm due to an increase in gastrointestinal hemorrhage. March 30, 2009 spirin to prevent CVD: women The USPSTF recommends the use of aspirin for women age 55 to 79 years when the potential benefit of a reduction in ischemic strokes outweighs the potential harm of an increase in gastrointestinal hemorrhage. March 30, 2009 bacteriuria The USPSTF recommends screening for asymptomatic bacteriuria with urine culture for pregnant women at 12 to 16 weeks' gestation or at the first prenatal visit, if later. July 31, high blood pressure recommends screening for high blood pressure in adults aged 18 and older. Dec 31, 2007 Counseling related to RC screening The USPSTF recommends that women whose family history is associated with an increased risk for deleterious mutations in RC1 or RC2 genes be referred for genetic counseling and evaluation for RC testing. Sept 30, 2005 breast cancer (mammography) The USPSTF recommends screening mammography for women with or without clinical breast examination (CE), every 1-2 years for women aged 40 and older. September 30, 2002 Chemoprevention of breast cancer The USPSTF recommends that clinicians discuss chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention. Clinicians should inform patients of the potential benefits and harms of chemoprevention. July 31, 2002 Interventions to support breast feeding The USPSTF recommends interventions during pregnancy and after birth to promote and support breastfeeding. Oct 31, cervical cancer The USPSTF strongly recommends screening for cervical cancer in women who have been sexually active and have a cervix. Jan 31, 2003 chlamydial infection: nonpregnant women recommends screening for chlamydial infection for all sexually active non-pregnant young women aged 24 and younger and for older non-pregnant women who are at increased risk chlamydial infection: pregnant women The USPSTF recommends screening for chlamydial infection for all pregnant women aged 24 and younger and for older pregnant women who are at increased risk cholesterol abnormalities: men 35 and older strongly recommends screening men aged 35 and older for lipid disorders. Mahoney&ssociates Creative Compensation & enefit Solutions

3 cholesterol abnormalities: men younger 35 The USPSTF recommends screening men aged 20 to 35 for lipid disorders if they are at increased risk for coronary heart disease. cholesterol abnormalities: women 45 and older The USPSTF strongly recommends screening women aged 45 and older for lipid disorders if they are at increased risk for coronary heart disease. cholesterol abnormalities: women younger than 45 The USPSTF recommends screening women aged 20 to 45 for lipid disorders if they are at increased risk for coronary heart disease. colorectal cancer The USPSTF recommends screening for colorectal cancer (CRC) using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75 years. The risks and benefits of these screening methods vary. Oct 31, Chemoprevention of dental caries The USPSTF recommends that primary care clinicians prescribe oral fluoride supplementation at currently recommended doses to preschool children older than 6 months of age whose primary water source is deficient in fluoride. pril 30, 2004 depression: adults The USPSTF recommends screening adults for depression when staff-assisted depression care supports are in place to assure accurate diagnosis, effective treatment, and follow-up. Dec 31, 2009 depression: adolescents The USPSTF recommends screening of adolescents (12-18 years of age) for major depressive disorder (MDD) when systems are in place to ensure accurate diagnosis, psychotherapy (cognitive-behavioral or interpersonal), and follow-up. March 30, 2009 diabetes The USPSTF recommends screening for type 2 diabetes in asymptomatic adults with sustained blood pressure (either treated or untreated) greater than 135/80 mm Hg. Counseling for a healthy diet The USPSTF recommends intensive behavioral dietary counseling for adult patients with hyperlipidemia and other known risk factors for cardiovascular and dietrelated chronic disease. Intensive counseling can be delivered by primary care clinicians or by referral to other specialists, such as nutritionists or dietitians. Jan 30, 2003 Supplementation with folic acid The USPSTF recommends that all women planning or capable of pregnancy take a daily supplement containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid. May 31, 2009 Mahoney&ssociates Creative Compensation & enefit Solutions

4 gonorrhea: wp,em recommends that clinicians screen all sexually active women, including those who are pregnant, for gonorrhea infection if they are at increased risk for infection (that is, if they are young or have other individual or population risk factors; go to Clinical Considerations for further discussion of risk factors). May 31, 2005 Prophylactic medication for gonorrhea: newborns The USPSTF strongly recommends prophylactic ocular topical medication for all newborns against gonococcal ophthalmia neonatorum. May 31, 2005 hearing loss The USPSTF recommends screening for hearing loss in all newborn infants. July 31, hemoglobinopathies The U. S. Preventive Services Task Force (USPSTF) recommends screening for sickle cell disease in newborns. Sept 30, 2007 hepatitis strongly recommends screening for hepatitis virus (HV) infection in pregnant women at their first prenatal visit HIV strongly recommends that clinicians screen for human immunodeficiency virus (HIV) all adolescents and adults at increased risk for HIV infection (go to Clinical Considerations for discussion of risk factors). July 31, 2005 congenital hypothyrodism The USPSTF recommends screening for congenital hypothyroidism (CH) in newborns. March 31, iron deficiency anemia The USPSTF recommends routine screening for iron deficiency anemia in asymptomatic pregnant women. May 31, 2006 Iron supplementation in children recommends routine iron supplementation for asymptomatic children aged 6 to 12 months who are at increased risk for iron deficiency anemia (go to Clinical Considerations for a discussion of increased risk). May 30, 2006 Screening and counseling for obesity: adults The USPSTF recommends that clinicians screen all adult patients for obesity and offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults. Dec 31, 2003 Screening and counseling for obesity: children The USPSTF recommends that clinicians screen children aged 6 years and older for obesity and offer them or refer them to comprehensive, intensive behavioral interventions to promote improvement in weight status. Jan 31, 2010 Mahoney&ssociates Creative Compensation & enefit Solutions

5 osteoporosis PKU Rh incompatibility: first pregnancy visit Rh incompatibility: weeks gestation Counseling for STIs syphilis: non-pregnant persons syphilis: pregnant women Counseling for tobacco use Counseling for tobacco use visual acuity in children The U.S. Preventive Services Task Force (USPSTF) recommends that women aged 65 and older be screened routinely for osteoporosis. The USPSTF recommends that routine screening begin at age 60 for women at increased risk for osteoporotic fractures. (Go to Clinical Considerations for discussion of women at increased risk.) The USPSTF recommends screening for phenylketonuria (PKU) in newborns. The U.S. Preventive Services Task Force (USPSTF) strongly recommends Rh (D) blood typing and antibody testing for all pregnant women during their first visit for pregnancyrelated care. The USPSTF recommends repeated Rh (D) antibody testing for all unsensitized Rh (D)- negative women at weeks' gestation, unless the biological father is known to be Rh (D)-negative. The USPSTF recommends high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs. The U.S. Preventive Services Task Force (USPSTF) strongly recommends that clinicians screen persons at increased risk for syphilis infection. The USPSTF recommends that clinicians screen all pregnant women for syphilis infection. The USPSTF recommends that clinicians ask all adults about tobacco use and provide tobacco cessation interventions for those who use tobacco products. The USPSTF recommends that clinicians ask all pregnant women about tobacco use and provide augmented, pregnancy-tailored counseling for those who smoke. The USPSTF recommends screening to detect amblyopia, strabismus, and defects in visual acuity in children younger than age 5 years. Sept 30, 2002 March 31, Feb 29, 2004 Feb 29, 2004 Oct 31, July 31, 2004 July 31, 2004 pril 30, 2009 pril 30, 2009 May 31, 2004 Mahoney&ssociates Creative Compensation & enefit Solutions

6 CTEGORY TWO IMMUNIZTIONS NOTE: Some of the following charts are a fraction of their normal size and are difficult, if not impossible to read. They can be enlarged by using the zoom feature on your computer. Mahoney&ssociates Creative Compensation & enefit Solutions

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9 SPECIL EFFECTIVE DTES FOR CERTIN IMMUNIZTIONS The following recommendations went into effect in whole or in part at some point after Sept 23, 2009: Meningococcal vaccine (in effect September 25, 2009) n expanded recommendation on meningococcal vaccine went into effect on September 25, The new recommendation only differs with respect to revaccination of individuals at increased risk. The prior recommendation had addressed revaccination for certain individuals who had previously received meningococcal polysaccharide vaccine; the new recommendation extends this to certain individuals who had previously received meningococcal conjugate vaccine. Therefore, plans and issuers with plan years (in the individual market, policy years) that begin on or after September 23, 2010 but before September 25, 2010 are required to provide coverage without cost-sharing for this service as described in the 2010 schedules, except that they are not required to provide coverage without cost-sharing for revaccination of certain individuals who had previously received meningococcal conjugate vaccine. Plans and issuers are required to provide coverage without costsharing for this service exactly as described in the 2010 schedules in the first plan year (in the individual market, policy year) that begins on or after September 25, Mahoney&ssociates Creative Compensation & enefit Solutions

10 SPECIL EFFECTIVE DTES FOR CERTIN IMMUNIZTIONS (continued) HPV (in effect January 8, 2010) n expanded recommendation on HPV vaccine went into effect on January 8, The new recommendation addresses vaccination with the bivalent (as opposed to quadrivalent) HPV vaccine for the first time; prior to January 8, 2010, the dvisory Committee did not make any recommendation on the bivalent vaccine. The new recommendation also addresses vaccination of males for the first time; prior to January 8, 2010, the CIP did not make any recommendation on the vaccination of males. Therefore, plans and issuers with plan years (in the individual market, policy years) that begin on or after September 23, 2010 but before January 8, 2011 are required to provide coverage without cost-sharing for this service as described in the 2010 schedules, except that they are not required to provide coverage without cost-sharing for vaccination with the bivalent vaccine or for vaccination of males. Plans and issuers are required to provide coverage without cost-sharing for this service exactly as described in the 2010 schedules in the first plan year (in the individual market, policy year) that begins on or after January 8, Influenza (in effect March 2, 2010) n expanded recommendation on influenza vaccine went into effect on March 2, Plans and issuers will be required to provide coverage without cost-sharing for this service as described in the recommendation and in the 2011 schedules in the first plan year (in the individual market, policy year) that begins on or after March 2, Read the full text of the recommendation. Pneumococcal vaccine (in effect March 12, 2010) n expanded recommendation on pneumococcal vaccine went into effect on March 12, Plans and issuers will be required to provide coverage without cost- sharing for this service as described in the recommendation and in the 2011 schedules in the first plan year (in the individual market, policy year) that begins on or after March 12, Read the full text of the recommendation. NOTE: Infection with Streptococcus pneumoniae bacteria can make children very sick. It causes blood infections, pneumonia, and meningitis, mostly in young children. lthough pneumococal meningitis is relatively rare (less than 1 case per 100,000 people each year), it is fatal in about 1 of 10 cases in children. efore routine use of pneumococcal conjugate vaccine, pneumococcal infections caused: over 700 cases of meningitis, 13,000 blood infections, about 5 million ear infections, and about 200 deaths annually in the United States in children under five. There are more than 90 types of pneumococcal bacteria. The new pneumococcal conjugate vaccine (PCV13) protects against 13 of them. These bacteria types are responsible for most severe pneumococcal infections among children. PCV13 replaces a previous conjugate vaccine (PCV7), which protected against 7 pneumococcal types and has been in use since During that time severe pneumococcal disease dropped by nearly 80% among children under 5. Combination Measles, Mumps, Rubella, and Varicella Vaccine (in effect May 7, 2010) new recommendation related to combination measles, mumps, rubella, and varicella vaccine went into effect on May 7, Plans and issuers will be required to provide coverage without cost sharing for this service as described in the recommendation and in the 2011 schedules in the first plan year (in the individual market, policy year) that begins on or after May 7, Mahoney&ssociates Creative Compensation & enefit Solutions

11 CTEGRORY THREE: PEDITRIC CRE right Futures Recommendations for Pediatric Preventive Health Care The comprehensive guidelines that are illustrated in the Periodicity Schedule of the right Futures Recommendations for Pediatric Preventive Health Care went into effect before September 23, 2009; therefore, plans and issuers are required to provide coverage without cost sharing for these services in the first plan year (in the individual market, policy year) that begins on or after September 23, Recommendations of the Secretary's dvisory Committee on Heritable Disorders in Newborns and Children The comprehensive guidelines that are illustrated in the Uniform Panel of the Secretary's dvisory Committee on Heritable Disorders in Newborns and Children went into effect May 21, Plans and issuers are required to provide coverage without cost-sharing for these services in the first plan year (in the individual market, policy year) that begins on or after May 21, Mahoney&ssociates Creative Compensation & enefit Solutions

12 CTEGRORY FOUR: HERITLE DISESES Mahoney&ssociates Creative Compensation & enefit Solutions

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14 CTUL REGULTION TEXT Through the wonders of incorporation by reference, the actual regulation is a masterpiece of brevity and reads in its entirety (sans examples) as follows: (a) Services (1) In general. eginning at the time described in paragraph (b) of this section, a group health plan, or a health insurance issuer offering group health insurance coverage, must provide coverage for all of the following items and services, and may not impose any cost-sharing requirements (such as a copayment, coinsurance, or deductible) with respect to those items or services: (i) Evidence-based items or services that have in effect a rating of or in the current recommendations of the United States Preventive Services Task Force with respect to the individual involved (except as otherwise provided in paragraph (c) of this section); (ii) Immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the dvisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved (for this purpose, a recommendation from the dvisory Committee on Immunization Practices of the Centers for Disease Control and Prevention is considered in effect after it has been adopted by the Director of the Centers for Disease Control and Prevention, and a recommendation is considered to be for routine use if it is listed on the Immunization Schedules of the Centers for Disease Control and Prevention); (iii) With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services dministration; and (iv) With respect to women, to the extent not described in paragraph (a)(1)(i) of this section, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by the Health Resources and Services dministration. (2) Office visits (i) If an item or service described in paragraph (a)(1) of this section is billed separately (or is tracked as individual encounter data separately) from an office visit, then a plan or issuer may impose cost-sharing requirements with respect to the office visit. (ii) If an item or service described in paragraph (a)(1) of this section is not billed separately (or is not tracked as individual encounter data separately) from an office visit and the primary purpose of the office visit is the delivery of such an item or service, then a plan or issuer may not impose cost-sharing requirements with respect to the office visit. (iii) If an item or service described in paragraph (a)(1) of this section is not billed separately (or is not tracked as individual encounter data separately) from an office visit and the primary purpose of the office visit is not the delivery of such an item or service, then a plan or issuer may impose cost-sharing requirements with respect to the office visit. - finis - Mahoney&ssociates Creative Compensation & enefit Solutions