Refer to the Healthcare Reform Preventive Care Services Coding document.

Latest Review Date: January 2024

Category: Administrative                                                      

POLICY:

Non-grandfathered plans should comply with “Recommended Preventive Services” for plan/policy years beginning on or after September 23, 2010, when rendered by an in-network provider.

The preventive services coverage requirements apply to the following general categories of preventive services, referred to as “Recommended Preventive Services”:

• Evidence-based services with a current “A” or “B” rating from the United States Preventive Services Task Force

• Immunizations recommended for routine use by the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention (children, adolescent, and adult)

• Child preventive care and screenings provided for in the guidelines supported by the Health Resources and Services Administration (HRSA) (Periodicity Schedule of the Bright Futures Recommendations and the Uniform Panel of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children). The comprehensive guidelines that are illustrated in the Uniform Panel of the Secretary's Advisory Committee on Heritable Disorders in Newborns and Children went into effect May 21, 2010. 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, 2011.

• For women, the preventive care and screenings provided for guidelines under development by the U.S. Department of Health and Human Services (HHS). 

HHS will maintain a complete and up-to-date list of Recommended Preventive Services (and their respective issue dates) on its web page:  www.healthcare.gov/center/regulations/prevention.html.

The Bright Futures recommendations are located on this webpage: www.aap.org/en/practice-management/bright-futures

The Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention recommendations are located on this webpage: www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/index.html

The patient’s medical record must contain clear documentation of the nature of the preventive service provided. 

DESCRIPTION OF PROCEDURE OR SERVICE:

The Patient Protection and Affordable Care Act (ACA) was signed into law in March 2010.  This law will reshape the benefits for Preventive Care services for certain plans.  ACA established the terms grandfathered and non-grandfathered to describe insurance plans requirements for compliance with various selections of ACA. Whether a plan is grandfathered or non-grandfathered is beyond the scope of this policy (see key points).

ACA requires non-grandfathered plans to provide coverage for “preventive care”.  This includes all non-grandfathered group health plans (insured and self-funded) and non-grandfathered individual policies issued or renewed on or after September 23, 2010.

Plans are not required to provide coverage for the recommended preventive services when they are delivered by out-of-network providers.  Cost-sharing may apply to additional preventive care services that a group may cover which are not included in the recommended preventive care services under ACA.

ACA defines preventive care services as follows:

• Items or services recommended with an A or B rating by the U.S. Preventive Services Task Force. 

• Immunization recommended by the Advisory Committee on Immunization Practices (ACIP) of the Center for Disease Control (CDC). (children, adolescent, and adult)

• Preventive care and screening for infants, children, and adolescents supported by the Health Resources and Services Administration (Bright Futures).

• Preventive care and screening for women supported by the Health Resources and Service Administration. 

The preventive services are covered without cost-sharing by the member (no co-pay or deductible).  Plans are only required to provide coverage and waive cost-sharing requirements for guidelines active at this time.  When new recommendations or guidelines are adopted, a plan is not required to provide coverage or delete cost-sharing until the 1st plan year/policy year beginning one year after the effective date of the new recommendation or guideline. For example, recommendations/guidelines issued prior to September 23, 2009, must be provided for plan years beginning on or after September 23, 2010. 

Plans may apply reasonable medical management techniques to determine the frequency, treatment, or setting for a recommended preventive service to the extent that it is not specified in the recommendation or guideline.

An office visit cost-share may apply to the office visit: (a) if the preventive service is billed separately from the office visit or (b) if the primary purpose of the office visit is other than the delivery of the recommended preventive service.  An office visit cost-share may not be applied to the office visit if: (a) the preventive service is not billed separately from the office visit and  (b) the primary purpose of the visit is the delivery of the recommended preventive service.

KEY POINTS:

The Patient Protection and Affordable Care Act (PPACA, ACA) was signed into law in March 2010. The ACA balances the objective of preserving the ability of individuals to maintain their existing coverage with the goals of insuring access to affordable essential coverage and improving the quality of coverage. While there are a number of reforms in ACA, this policy only addresses the coverage requirements for the “Recommended Preventive Services”.

The preventive services requirements apply to the following general categories of preventive services, referred to as “Recommended Preventive Services,” when furnished by an in-network provider:

• Evidence-based services with a current “A” or “B” rating from the United States Preventive Services Task Force

• Immunizations recommended for routine use by the Advisory Committee on Immunization Practices at the Centers for Disease Control and Prevention (children, adolescent, and adult)

• Child preventive care and screenings provided for in the guidelines supported by the Health Resources and Services Administration (HRSA)

• For women, the preventive care and screenings provided for guidelines under development by the U.S. Department of Health and Human Services (HHS). 

Coverage of Recommended Preventive Services furnished by out-of-network providers is not required under Healthcare Reform.

Those Recommended Preventive Services issued prior to September 23, 2009, must be covered by plans/policies effective as of the first day of the first plan/policy year beginning on or after September 23, 2010.  Coverage for Recommended Preventive Services issued after September 23, 2009, must be effective as of the first day of the first plan/policy beginning on or after the one-year anniversary of the date the recommendation or guideline is issued.

Non-grandfathered group health plans and health insurance issuers offering non-grandfathered group and individual health insurance coverage must comply with the preventive services coverage requirements for plan/policy years beginning on or after September 23, 2010.

Grandfathered group health plans and health insurance issuers offering grandfathered group and individual health insurance coverage are not required to comply with the preventive services coverage requirements.

Grandfathered status may be lost if any of the following occur within the plan:

1. Elimination of benefits to diagnose or treat a particular condition.

2. Increase in percentage cost-sharing.

3. Increase in a fixed-amount cost-sharing requirement other than a co-payment.

4. Increase in a fixed-amount co-payment.

5. Decrease in contribution rate by employers and employee organizations.

6. Change in annual limits.  Addition of an annual limit or decrease in limit for a plan, coverage with only a lifetime limit or decrease in limit for a plan or coverage with an annual limit.

Cost-sharing requirements, including deductibles, co-payments and co-insurance, are prohibited for Recommended Preventive Services furnished by in-network providers.  Coverage of Recommended Preventive Services furnished by out-of-network providers is not required, and if coverage is provided, cost-sharing obligations may be imposed.

Recognizing that the Recommended Preventive Services frequently may be furnished as part of office visits in which other healthcare services are provided, the federal agencies have adopted the following rules relating to cost-sharing requirements for such other services:

• If a Recommended Preventive Service is billed separately from an office visit, a cost-sharing obligation may be imposed with respect to the office visit (but not the Recommended Preventive Service)

• If (1) A Recommended Preventive Service is not billed separately from an office visit, and (2) the primary purpose of the office visit is the provision of the Recommended Preventive Service, a cost-sharing obligation may not be imposed for the office visit or the Recommended Preventive Service

• If (1) a Recommended Preventive Service is not billed separately from an office visit, and (2) the primary purpose of the office visit is not the provision of the Recommended Preventive Service, a cost-sharing obligation may be imposed for the office visit (but not for the Recommended Preventive Service)

Medical management rules such as frequency, method treatment or site of service, not already specified in the “Recommended Preventive Services” may be established by the payer.

KEY WORDS:

Healthcare Reform, HCR, preventive services, routine services, Affordable Care Act, ACA, Patient Protection and Affordable Care Act, PPACA 

APPROVED BY GOVERNING BODIES:

Not applicable

Benefit Application:

Coverage is subject to member’s specific benefits.  Group-specific policy will supersede this policy when applicable.

ITS: Home Policy provisions apply

CODING:

CPT Codes:

To ensure the accurate processing of claims for the ACA Preventive services, specific coding has been identified for each service.  Please refer to the information at the end of this document for Blue Cross and Blue Shield of Alabama coding requirements for these services.

Modifier 33, Preventive Service:

When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with the modifier 33.

*Note: The correct coding for both ICD-10 and CPT or HCPC’s code are also required as listed in the coding instructions of the Preventive Care Services document.

REFERENCES:

1. Advisory Committee on Immunization Practices (ACIP) Recommendations. http://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/index.html
2. Agency for Healthcare Research and Quality (AHRQ).  U.S. Preventive Services Task Force (USPSTF).  www.ahrq.gov/clinic/uspstfix.htm.
3. American Academy of Pediatrics/Bright Futures.  Recommendations for Preventive Pediatric Healthcare.  American Academy of Pediatrics https://www.aap.org/en/practice-management/bright-futures
4. American Academy of Pediatrics. Bright Futures: Coding for Pediatric Preventive Care Booklet, 2022. https://downloads.aap.org/AAP/PDF/Coding%20Preventive%20Care.pdf
5. Centers for Disease Control (CDC). Immunization Schedules. Vaccines and Immunizations, www.cdc.gov/vaccines/recs/schedules/default.htm.
6. Healthcare.gov. Recommended Preventive Services. Implementation Center, www.healthcare.gov/center/regulatins/prevention/recommendations.html.
7. Healthcare.gov. Preventive Regulations. Implementation Center, www.healthcare.gov/center/regulations/prevention/regs.html.
8. National Archives and Records Administration. Group Health Plans and Health Insurance Coverage Relating to Status as a Grandfathered Health Plan under the Patient Protection and Affordable Care Act; Interim Final Rule and Proposed Rule. Federal Register, June 17, 2010, Part II, Department of the Treasury, Internal Revenue Service 26 CFT Parts 54 and 602; Department of Labor, Employee Benefits Security Administration, 29 CFR Part 2590; Department of Health and Human Services, 45 CFT Part 147.
9. SACHDNC Recommended Uniform Screening Panel. Core Conditions. August 2022. https://www.hrsa.gov/advisory-committees/heritable-disorders/rusp/index.html
10. Women’s Preventive Services Guidelines (HRSA) https://www.hrsa.gov/womens-guidelines-2016/index.html.

POLICY HISTORY:

Medical Policy Group, September 2010 (3)

Medical Policy Administration Committee, September 2010

Available for comment September 30-November 15, 2010

Medical Policy Group, December 2010 (2)

Medical Policy Administration Committee, January 2010

Available for comment January 11 through February 21, 2011

Medical Policy Group, August 2011 (3); Added Q codes to Coding Instruction Table

Medical Policy Administration Committee, September 2011

Available for comment September 2, 2011 through October 17, 2011

Medical Policy Group, December 2011 (2), New Guidelines, 2012 coding updates added

Medical Policy Administration Committee, January 2012

Available for comment, March 2 – May 30, 2012

Coding document retired and reference to web link for Quick Reference Guide for Preventative Services under HCR. 

Medical Policy Group, January 2015 (3): Literature and consensus review completed; no updates required at this time; no change in policy statement

Medical Policy Group, July 2017 (3): Literature and consensus review completed; no updates required at this time; no change in policy statement

Medical Policy Group, July 2017 (3): Literature and consensus review completed; no updates required at this time; no change in policy statement

Medical Policy Group, July 2018 (7): Literature and consensus review completed; no updates required at this time; no change in policy statement

Medical Policy Group, April 2019 (7): Literature and consensus review completed; no updates required at this time; no change in policy statement Added Keywords: Affordable Care Act, ACA, Patient Protection and Affordable Care Act, PPACA. 

Medical Policy Group, January 2021 (7): Literature and consensus review completed; no updates required at this time; no change in policy statement

Medical Policy Group, February 2022 (7): Literature and consensus review completed. References updated; no change in policy statement

Medical Policy Group, January 2023 (7): Literature and consensus review completed. References updated; no change in policy statement

Medical Policy Group, January 2024 (7): Literature and consensus review completed. Updated note under Coding Section- removed “ICD-9” and added “ICD-10”. No change in Policy Statement.

This medical policy is not an authorization, certification, explanation of benefits, or a contract. Eligibility and benefits are determined on a case-by-case basis according to the terms of the member's plan in effect as of the date services are rendered. All medical policies are based on (i) research of current medical literature and (ii) review of common medical practices in the treatment and diagnosis of disease as of the date hereof. Physicians and other providers are solely responsible for all aspects of medical care and treatment, including the type, quality, and levels of care and treatment.

This policy is intended to be used for adjudication of claims (including pre-admission certification, pre-determinations, and pre-procedure review) in Blue Cross and Blue Shield’s administration of plan contracts.

The plan does not approve or deny procedures, services, testing, or equipment for our members. Our decisions concern coverage only. The decision of whether or not to have a certain test, treatment or procedure is one made between the physician and his/her patient. The plan administers benefits based on the member's contract and corporate medical policies. Physicians should always exercise their best medical judgment in providing the care they feel is most appropriate for their patients. Needed care should not be delayed or refused because of a coverage determination.

As a general rule, benefits are payable under health plans only in cases of medical necessity and only if services or supplies are not investigational, provided the customer group contracts have such coverage.

The following Association Technology Evaluation Criteria must be met for a service/supply to be considered for coverage:

1. The technology must have final approval from the appropriate government regulatory bodies;
2. The scientific evidence must permit conclusions concerning the effect of the technology on health outcomes;
3. The technology must improve the net health outcome;
4. The technology must be as beneficial as any established alternatives;
5. The improvement must be attainable outside the investigational setting.

Medical Necessity means that healthcare services (e.g., procedures, treatments, supplies, devices, equipment, facilities or drugs) that a physician, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing or treating an illness, injury or disease or its symptoms, and that are:

1. In accordance with generally accepted standards of medical practice; and
2. Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the patient’s illness, injury or disease; and
3. Not primarily for the convenience of the patient, physician or other healthcare provider; and
4. Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of that patient’s illness, injury or disease.