ACP has received a number of inquiries from members about coverage of and coding for preventive services that are mandated by the Affordable Care Act (ACA).
Q: What preventive medical services are now covered?
A: Since September 2010, the ACA has required both individual and employer group insurance plans (including self-insured plans) to cover, at a minimum, evidence-based items and services that the U.S. Preventive Services Task Force (USPSTF) has rated “A” or “B.” The requirement applies if the insurance plan was established after March 23, 2010, and if the preventive service is provided by an in-network physician or other in-network health care professional.
It is important to note that plans that were in existence on or before March 23, 2010, and meet the definition of a “grandfathered” plan are not required to abide by this provision. To determine which of your patients are in grandfathered plans, you may need to contact their insurance payers or their employers' human resources departments.
These preventive services are exempt from deductibles, co-insurance or copayments because the ACA prohibits cost sharing for core preventive services. Insurers are allowed to cover additional preventive benefits beyond those given a rating of “A” or “B” by the USPSTF.
In the USPSTF ratings, an “A” rating means that the service is recommended and that there is a high level of certainty that it will yield substantial benefit to the patient. A “B” rating indicates that the service is recommended and that there is a high level of certainty that the services will yield at least a moderate benefit to the patient.
Under the ACA, insurers are required to cover these preventive services:
- recommended immunizations,
- preventive care for infants, children and adolescents, and
- additional services for women, as outlined in comprehensive guidelines supported by the Health Resources and Services Administration (HRSA).
Q: What about preventive services that don't receive an “A” or “B” rating?
A: A plan or insurer is permitted to cover or deny additional preventive services not recommended by the USPSTF.
The USPSTF recommendations change over time; current recommendations are online. The law requires the U.S. Department of Health and Human Services to update required services following the release of new or revised recommendations, which the agency does online.
Q: How do we know a patient is eligible for free preventive services?
A: The preventive services are not applicable to every patient in every situation.
In addition to the requirement that physicians be in-network, a federal regulation also established a number of other rules to determine whether an insurer is required to cover a preventive service without cost sharing.
- If the recommended preventive service is not billed separately from an office visit and if the primary purpose of the office visit is the delivery of a preventive service, then the plan may not impose cost-sharing requirements to the office visit.
- If a recommended preventive service is billed separately from an office visit, then the plan may impose cost-sharing requirements to the office visit.
- If a recommended preventive service is not billed separately from an office visit and if the primary purpose of the office visit is not the delivery of a preventive service, then the plan may impose cost-sharing requirements to the office visit.
- An insurer is permitted to use “reasonable medical management” to determine the frequency, method, treatment or setting for a recommended preventive item or service if such information is not provided in the recommendation.
- If a service/item is no longer recommended by USPSTF, HRSA or another agency, insurers are no longer required to provide the service or item without cost sharing. Insurers are required to alert their enrollees of revision of benefit plans.
Q: How does a payer identify a preventive service on a claim?
A: Insurers can use a combination of the CPT, HCPCS, and ICD-9 or ICD-10 codes to denote a preventive service. Some of these codes are already familiar to you, such as CPT 99408 and CPT 99409 for alcohol misuse screening; HCPCS G0101 for cervical cancer screening; and CPT 82947, CPT 82950 or CPT 82951 for diabetes screening tests.
However, there is also a CPT modifier that, when used correctly, clearly identifies ACA preventive services: modifier 33. The full text of the modifier's description is stated in Appendix A of the CPT code book: “When the primary purpose of the service is the delivery of an evidence based service in accordance with a U.S. 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 identified by adding 33 to the procedure code. For separately reported services specifically identified as preventive, the modifier should not be used.”
Additionally, many payers have created reference tools for preventive services (with corresponding billing codes) covered by their plans; many of those lists are online or included in clinician newsletters. Check with payers for specific information.