ACA first-dollar coverage for preventive services

I N F O R M A T I O N U P D A T E September 2014 ACA first-dollar coverage for preventive services The Affordable Care Act (ACA) mandates that all non-grandfathered group and individual health plans must provide coverage for preventive services with no member cost share, when provided by in-network providers. In accordance with the ACA requirements, Wellmark will provide first-dollar coverage for preventive services when they are provided by in-network providers (benefit coverage and cost sharing will apply for out-of-network services as specified in the benefit document). Health plans may apply cost sharing to outof-network preventive care, and they may utilize reasonable medical management techniques to help control costs and promote efficient delivery of care. How preventive care services are defined: Preventive services are defined under the ACA as those immunizations, screenings, and other services that are listed as recommended by the United States Preventive Services Task Force (USPSTF), the Health Resources Services Administration (HRSA), or the federal Centers for Disease Control (CDC).* Important note: The services identified are recommendations by ACA to clinicians, not mandated services. It is up to the clinician to decide which services to provide. Preventive health services list Below is a representative list of the preventive health services that are required to be covered with no member cost-share, if provided by an in-network provider. This list is based on information available online at the following USPSTF site which contains additional qualifiers: http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm HCR13-012 Wellmark Blue Cross and Blue Shield is an Independent Licensee of the Blue Cross and Blue Shield Association

Preventive health services covered under the Affordable Care Act (ACA) This list is not all-inclusive, and benefits are not guaranteed. Please see the Notes section below. MEN & WOMEN WOMEN ONLY Adult immunizations includes: Hepatitis A; Hepatitis B; Herpes Zoster; Human Papillomavirus; Influenza (Flu Shot); Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Tetanus, Diptheria, Pertussis; Varicella Alcohol misuse screening and behavioral counseling interventions Aspirin for the prevention of cardiovascular disease in men and women of certain ages (prescription required for full coverage) Colorectal cancer screening colonoscopy, sigmoidoscopy, laboratory and pathology for adults over 50 Depression screening Diabetes screening (Type 2 Diabetes for adults with high blood pressure) Diet and behavioral counseling in primary care to promote a healthy diet (for adults who are at risk for chronic disease) Hepatitis C screening in persons at high risk for infection and one-time screening for adults born between 1945 and 1965 High blood pressure screening HIV screening for all adults at higher risk Lipid screening (Cholesterol screening) for adults of certain ages or those at higher risk Obesity screening and counseling for at risk populations Sexually transmitted infections counseling for at risk populations Breast Cancer Chemoprevention counseling for those who are at higher risk Breast cancer screening (including mammography) every 1-2 years for women over age 40 Cervical cancer screening Chlamydia screening for all sexually active non-pregnant women aged 24 and younger, and older non-pregnant women at higher risk Contraception and contraceptive counseling: this applies to FDA-approved contraceptive methods for women Domestic violence screening and counseling: annual screening and counseling for interpersonal and domestic violence available to women Gonorrhea screening Human Papillomavirus (HPV) DNA test: women 30 and older may receive high-risk HPV screening every three years, regardless of Pap test results Osteoporosis screening Screening, evaluation and counseling for the BRCA breast cancer gene, for at-risk women. Sexually Transmitted Infections (STI) and HIV screening and counseling: annual counseling on HIV and STIs for sexually active women Syphilis infection screening for those at higher risk Well-woman visits, including annual well-woman preventive care office visits Syphilis infection screening for at risk populations Tobacco use screening, counseling and cessation interventions including FDA-approved tobacco cessation medications MEN ONLY Abdominal Aortic Aneurysm one-time screening aged 65-75 who have ever smoked 2

PREGNANT WOMEN Asymptomatic bacteriuria screening (UTI) Chlamydia screening for all pregnant women aged 24 and younger, and for older pregnant women at higher risk Daily folic acid supplements for women capable of becoming pregnant (prescription required for full coverage) Gestational diabetes screening for at-risk pregnant women, between 24-28 weeks of gestation Gonorrhea screening for those who are at higher risk Hepatitis B virus infection screening at first prenatal visit HIV screening Iron deficiency anemia screening Primary care interventions to promote breastfeeding. Breast feeding support, supplies and counseling: counseling may be provided during pregnancy and/or in the postpartum period. Only manual breast pumps are covered with no member cost share. Rh (D) blood typing and antibody testing for incompatibility screening Sexually transmitted infections counseling STD testing based on risk (other than Chlamydia and HIV) Syphilis infection screening for those at higher risk Tobacco use screening and counseling NEWBORNS/CHILDREN/ ADOLESCENTS Alcohol screening and counseling Autism screening for children at 18 and 24 months Behavioral assessments for children of all ages Blood pressure screening Cervical dysplasia screening for sexually active females Congenital hypothyroidism screening for newborns NEWBORNS/CHILDREN/ADOLESCENTS (continued) Developmental screening for children under age 3, and surveillance throughout childhood Dyslipidemia screening for those at higher risk of lipid disorders Gonorrhea, prophylactic medication for newborns Fluoride treatment for children Hearing screening for newborns Height, Weight and Body Mass Index measurements Hematocrit or Hemoglobin screening HIV screening for adolescents at higher risk Immunizations includes: Diphtheria, Tetanus, Pertussis; Haemophilus influenza type b; Hepatitis A; Hepatitis B; Human Papillomavirus; Inactive Poliovirus; Influenza (Flu Shot); Measles, Mumps, Rubella; Meningococcal; Pneumococcal; Rotavirus; Varicella Iron supplements for at risk infants 6-12 months (prescription required for full coverage) Lead screening for children at risk to exposure Major depressive disorder screening for children and adolescents Medical history for all children throughout development Oral health risk assessment for young children 10 or under Phenylketonuria (PKU) screening for newborns Screening and interventions for childhood obesity Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk Sickle Cell disease screening for newborns Tobacco use interventions Tuberculin testing for children at higher risk of Tuberculosis Visual impairment screening for children under the age of 5 3

Recently released A and B recommendations: Breast cancer preventive medications for women, age 35 and older, and who are at an increased risk for breast cancer and at low risk for adverse medication effects (effective the first plan year that begins on or after 10/1/14). Annual Computed Tomography (CT) scan for at-risk adults ages 55 to 80 with a 30 pack-year history, and currently smoke or have quit within the past 15 years (effective the first plan year that begins on or after 1/1/15). BRCA 1 or BRCA 2 testing, if indicated after genetic counseling (effective the first plan year that begins on or after 1/1/15). Hepatitis B screening for persons at high risk for infection (effective the first plan year that begins on or after 1/1/15). Dental caries prevention: infants and children up to age 5 years (effective the first plan year that begins on or after 1/1/15). Additional information: Members of Wellmark Health Plan of Iowa are required to receive most preventive services from their designated primary care practitioners. Prior authorization policies for selected services will remain in place. Claims for covered immunizations, whether submitted and paid under a Blue Rx plan when received at pharmacies that contract for immunizations, or under a health plan, are covered with no member cost share. An annual physical and an annual OB/GYN exam received from in-network clinicians will be provided with no member cost share. Notes: Age and gender limitations may apply. For more information on required preventive services, go to the federal government s health care reform site: http://www.hhs.gov/healthcare/facts/factsheets/2010/ 07/preventive-serviceslist.html#CoveredPreventiveServicesforAdults Wellmark will apply its standard medical management policies and procedures, as specifically mentioned and allowed under the Affordable Care Act. Please note that there are differences between preventive screenings, exams and services vs. treatment for specific diseases and illnesses. The following is a link to the recommended immunizations schedules: http://www.cdc.gov/vaccines/schedules/index.html. *Section 2713 of the ACA references recommendations by the USPSTF, the HRSA, and the CDC. The United States Preventive Services Task Force is a federal agency that makes its recommendations on the basis of explicit criteria. Recommendations issued by the USPSTF are intended for use in the primary care setting. The Task Force recommendation statements present health care providers with information about the evidence behind each recommendation, allowing clinicians to make informed decisions about implementation. Wellmark consults with the Task Force regularly to determine how preventive services may be covered. The Health Resources and Services Administration (HRSA), an agency of the U.S. Department of Health and Human Services, (HHS) is the primary Federal agency for improving access to health care services for people who are uninsured, isolated or medically vulnerable. The Centers for Disea se Control and Prevention: one of the major operating components of the Department of Health and Human Services, CDC s Mission is to collaborate to create the expertise, information, and tools that people and communities need to protect their health through health promotion, prevention of disease, injury and disability, and preparedness for new health threats. 4

Wellmark is not providing any legal advice with regard to compliance with the requirements of the Affordable Care Act (ACA) or the Mental Health Parity Addiction Equity Act (MHPAEA). Regulations and guidance on specific provisions of the ACA and MHPAEA have been and will continue to be provided by the U.S. Department of Health and Human Services (HHS) and/or other agencies. The information provided reflects Wellmark's understanding of the most current information and is subject to change without further notice. Please note that plan benefits, rates, renewal rate adjustments, and rating impact calculations are subject to change and may be revised during a plan s rating period based on guidance and regulations issued by HHS or other agencies. Wellmark makes no representation as to the impact of plan changes on a plan's grandfathered status or interpretation or implementation of any other provisions of ACA. Any questions about Wellmark's approach to the ACA or MHPAEA may be referred to your Wellmark account representative. Wellmark will not determine whether coverage is discriminatory or otherwise in violation of Internal Revenue Code Section 105(h). Wellmark also will not provide any testing for compliance with Internal Revenue Code Section 105(h). Wellmark will not be held liable for any penalties or other losses resulting from any employer offering coverage in violation of section 105(h). Wellmark will not determine whether any change in an Employer Administered Funding Arrangement affects a health plan s grandfathered health plan status under ACA or otherwise complies with ACA. Wellmark will not be held liable for any penalties or other losses resulting from any Employer Administered Funding Arrangement. For purposes of this paragraph, an Employer Administered Funding Arrangement is an arrangement administered by an employer in which the employer contributes toward the member s share of benefit costs (such as the member s deductible, coinsurance, or copayments) in the absence of which the member would be financially responsible. An Employer Administered Funding Arrangement does not include the employer s contribution to health insurance premiums or rates. 5