Preventive Services Update: Fall Prevention Services and Intimate Partner Screening and Intervention

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1 Date: April 29, 2013 Market: All Preventive Services Update: Fall Prevention Services and Intimate Partner Screening and Intervention Overview On August 1, 2011 HHS published an amendment to the September 23, 2010 Patient Protection and Affordable Health Care Act (known as PPACA or Federal Health Care Reform) Preventive Services that adds additional preventive services that must be covered at zero-cost share to members. Description of Additional Preventive Service at Zero Cost Share Fall Prevention Services Older adults living at home (referred to as community-dwelling) have an increased risk for falling. Physical therapy and OTC Vitamin D supplementation can help improve balance and strengthen bones to help prevent falls for these members. For members aged 65 and over living at home, physical therapy prescribed by the member s provider and prescription strength or OTC Vitamin D supplements with a physician prescription purchased at a pharmacy will be covered at zero-cost share. Fall prevention services are not available to adults residing in assisted living facilities or nursing homes. Note: this benefit does not apply to Medicare Supplemental products. Intimate Partner Violence Screening and Intervention The United States Preventive Services Task Force (USPSTF) recommends that clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services. This recommendation applies to women who do not have signs or symptoms of abuse and will be covered as a Women s Preventive Service. Effective Date & Implementation Fall Prevention and Intimate Partner Violence Screening and Intervention are covered at zero cost share for new business effective May 1, Existing products that accept PPACA services will receive the new benefits on or after May 1, Contracts There is no impact to the group benefit contract. Benefit Summary There is no impact to online Benefit Summaries. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.

2 Account Communications Attached is an account communication template you may use to notify your accounts of this new benefit. A revised Summary of Preventive Services is attached to this Broker Flash. Please use this new version. Frequently Asked Questions (FAQs) Q. In regard to the Fall Prevention services for physical therapy and Vitamin D (OTC) supplementation to prevent falls in adults who live at home (those not in assisted living facilities or nursing homes), does this apply to contracts for Medicare Supplemental members? A. Medicare Supplemental contracts are not subject to PPACA legislation and are not covered by the Preventive Services Provision of the PPACA. Q. What about over 65 members who remain on their employers group coverage? A. Yes, they are covered by the Fall Prevention benefit and other services under the Preventive Services Provision of the PPACA. Q. How do Fall Prevention services coordinate with Medicare? A. Medicare coverage is not subject to PPACA legislation and is not covered by this preventive benefit. Q. Am I correct in assuming the Vitamin D (OTC) is only covered if we have their pharmacy coverage? A. CareFirst has implemented pharmacy preventive services in the past that are tied to the Rx product. So for a group that may have carved out their pharmacy benefits, their carved-out pharmacy plan should cover the benefit. For our products such as Personal Comp that do not have PBM benefits, the same process would be followed as the rest of the OTC drugs covered by the Preventive Services provision. They submit the claim along with a prescription and CareFirst processes. If a group has NO pharmacy plan with ANYONE, then we will have to cover the benefit under medical. If you have any questions, please contact your Broker Sales Representative. Shekar Subramaniam Associate Vice President, Broker Sales CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are both independent licensees of the Blue Cross and Blue Shield Association.

3 April 26, 2013 [Company Name] [Address] [City, State Zip] Dear [Group Administrator Name]: CareFirst BlueCross BlueShield is committed to providing you with the most current information regarding your health care plan. This letter outlines new additions to the Patient Protection and Affordable Health Care Act (known as PPACA or Federal Health Care Reform) that offers preventive services covered at zero-cost share to our members. Effective [May 1, 2013 for risk accounts, renewal date for ASO accounts], these services will be added to plans that currently cover the PPACA Preventive Services: Fall Prevention Services Older adults living at home (referred to as community-dwelling) have an increased risk for falling. Physical therapy and OTC Vitamin D supplementation can help improve balance and strengthen bones to help prevent falls for these members. For members aged 65 and over living at home, physical therapy prescribed by the member s provider and over-thecounter (OTC) Vitamin D supplements with a physician prescription purchased at a pharmacy will be covered at zero-cost share. Fall prevention services are not available to adults residing in assisted living facilities or nursing homes. Note: This benefit does not apply to Medicare Supplemental products. Intimate Partner Violence Screening and Intervention The United States Preventive Services Task Force (USPSTF) recommends that clinicians screen women of childbearing age for intimate partner violence, such as domestic violence, and provide or refer women who screen positive to intervention services. This recommendation applies to women who do not have signs or symptoms of abuse and will be covered as a Women s Preventive Service. If you have any questions, please contact me at [INSERT PHONE] OR [INSERT ADDRESS]. Sincerely, [Insert signature] [Insert Your Name] [Insert Your Title] CareFirst BlueCross BlueShield is an independent licensee of the Blue Cross and Blue Shield Association.

4 Summary of Preventive Services As of April, 2013 The preventive services set forth below apply to plans that have elected or are required to provide preventive services under the Patient Protection and Affordable Care Act. Such preventive services are covered where clinically appropriate, under recommendations of the United States Preventive Services Task Force and supporting evidence. Limitations may apply with respect to the availability, setting, frequency, or method of a service or treatment. Children Well child visits (birth to age 21) to include: Screenings for autism Developmental screenings - under age 3 Hearing screenings for newborns Screening for cervical dysplasia for sexually active females Hematocrit or hemoglobin screenings HIV screening Vision screening Obesity screening Testing for lead Certain diagnostic screenings for newborns Immunizations for Children Diphtheria, Tetanus, Pertussis Hepatitis A Human Papillomavirus Influenza Influenza B Measles, mumps and rubella Meningococcal Pneumococcal Varicella Rotavirus Inactivated Polio Health, diet and weight counseling Alcohol and drug assessments for older children Adults Preventive Care Visits include screenings for: Cholesterol High blood pressure Type 2 diabetes Depression Alcohol misuse HIV Obesity One-time screening of abdominal aortic aneurysm Osteoporosis Anemia Cervical cancer screening Sexually transmitted diseases Rh incompatibility and urinary tract infection screenings for pregnant women Mammograms Colonoscopies Gestational diabetes screening HPV DNA testing Intimate partner, interpersonal and domestic violence screening and counseling Breastfeeding support, supplies and counseling 1 FDA approved contraceptive methods and counseling 2 Health, diet and weight counseling for qualifying adults Tobacco use screenings and cessation counseling 1 See next page for details 2 See next page for complete listing Immunizations for Adults Hepatitis A Herpes Zoster HPV Influenza Measles, mumps and rubella Diphtheria, Tetanus, Pertussis Meningococcal Pneumococcal Varicella

5 Preventive Drugs for Children Fluoride preschool age (P) Iron 6-12 mo. risk of anemia (OTC*) Preventive Drugs for Adults Folic Acid women of childbearing age (P) Smoking Cessation (OTC*) Aspirin (81mg) (OTC*) FDA Approved Contraceptives Female Condom (OTC*) Diaphragm (P) with Spermicide (OTC*) Sponge (OTC*) with Spermicide (OTC*) Cervical Cap (P) with Spermicide (OTC*) Spermicide (OTC*) Oral Contraceptive (generics) (P) Oral Contraceptive (brand name (P) only when generic equivalent drug is medically inappropriate, as determined by the individual s health care provider). Pre authorization and medical review of brand oral contraceptives is required. Contraceptive Patch (P) Contraceptive Ring (P) Shot/Injection 3 (generic only) (P) Morning After Pill (generic only) (OTC*) IUD (inserted by doctor) Contraceptive Implant System (inserted by doctor) Sterilization Implant Sterilization Surgery 3 Includes Brand Name Depo-SubQ Provera 104 (injection) Breastfeeding Supplies Provided under the Durable Medical Equipment (DME) benefits of the contract Coverage is provided for: Manual breast pumps (rental and/or purchase) Electric breast pump (rental and/or purchase) Hospital grade electric breast pump (rental) Replacement supplies include: Breast pump replacement tubing Adapter for breast pump Cap for breast pump bottle Breast shield & splash protector for use with breast pump Polycarbonate bottle for use with breast pump Locking ring for breast pump Prenatal and Postnatal Care Routine prenatal obstetrical office visits Prenatal laboratory diagnostic tests and services related to the outpatient care of an uncomplicated pregnancy One postpartum office visit Fall Prevention Physical therapy and Vitamin D (OTC*) supplementation to prevent falls in communitydwelling adults (those who are not in assisted living facilities or nursing homes), age 65 years or older who are at increased risk for falls. BRAC Testing BRAC testing for breast/ovarian cancer risk and genetic counseling (P) Prescription Required (OTC) Over the Counter * Requires a prescription from a physician and must be purchased at a pharmacy to obtain the zero-cost share. Indicates service added as of August 1, 2012 as part of the recommended services for women. Additional information on Preventive Services is available at Breast Pumps and Supplies