The Affordable Care Act Increases Preventive Health Services for Adults, Children, and Seniors
Patients May Be Eligible for Free Preventive Health Services
The Affordable Care Act (ACA) requires insurers to cover many preventive health services for policies that renewed after September 23, 2010. The covered services, including colonoscopy screening, Pap smears, well-child visits, and flu shots, are consistent with recommendations from the American Academy of Family Practice, the American Academy of Pediatrics, and other professional societies.[2,3] The US Department of Health and Human Services estimates that this law has increased preventive services for 54 million Americans. It is quite likely that many of your patients are part of these 54 million people. Review the list below and consider whether your patients could benefit from these services.
Not only do these benefits exist for privately insured patients, the new cost-sharing benefits extend to your Medicare patients as well. Before the Affordable Care Act, Medicare beneficiaries enjoyed access to some preventive services without a cost-sharing requirement; however, the new law expanded the cost-sharing provisions to all Medicare-covered preventive services. The Affordable Care Act also gave Medicare additional flexibilities to add to the portfolio of preventive services covered by the program, if needed. It is important to note that your office should follow Medicare billing rules closely to be sure that preventive services claims are submitted correctly -- this will ensure beneficiaries can take full advantage of their preventive service benefits at no cost. For a compendium of billing, coding, and eligibility resources on the use of the different preventive benefits, visit CMS.gov.
The tables below show the preventive services for different patient populations that must be covered without requiring the patient to contribute through a copayment or coinsurance or by meeting a deductible. For more specific information about these services, visit healthcare.gov. Covered Preventive Health Services by Patient Population
Adults: • Screening for: o Abdominal aortic aneurysm o Alcohol misuse (and counseling) o Blood pressure o Cholesterol o Colorectal cancer o Depression o Type 2 diabetes o HIV o Obesity (and counseling) o Tobacco use (and cessation interventions) o Syphilis • Aspirin • Diet counseling • Immunizations: o Hepatitis A and B o Herpes zoster o Human papillomavirus (HPV) o Influenza (flu shot) o Measles, mumps, rubella o Meningococcal o Pneumococcal o Tetanus, diphtheria, pertussis o Varicella • Sexually transmitted infection counseling
Women, Including Pregnant Women: • Screening for: o Anemia o Bacteriuria urinary tract infection or other infection o Cervical cancer o Chlamydia infection o Domestic and interpersonal violence (and counseling) o Gestational diabetes o Gonorrhea o Hepatitis B o HIV o Human papillomavirus o Osteoporosis o Rh incompatibility o Syphilis o Tobacco use (and cessation interventions) • Breast cancer mammography • Breast cancer chemoprevention counseling • BRCA counseling and genetic testing • Breastfeeding counseling and supplies • Contraception and counseling • Folic acid supplements • Sexually transmitted infection counseling • Well-woman visits
Seniors[5,6]: • Screening for: o Abdominal aortic aneurysm o Alcohol misuse o Blood tests for cardiovascular disease risk factors (cholesterol, lipids, triglycerides) o Breast cancer (including screening mammogram) o Cervical cancer (including Pap smear test and pelvic exam) o Colorectal cancer o Depression o Diabetes o HIV o Obesity o Osteoporosis through bone mass measurement o Prostate cancer o Some sexually transmitted diseases • Annual wellness visit for established Medicare patients • Behavioral therapy for cardiovascular disease • Counseling for alcohol misuse • Counseling for obesity • Glaucoma testing • Immunizations including: o Hepatitis B o Influenza o Pneumococcal • Initial preventive physical examination (“Welcome to Medicare”) visit for new Medicare patients • Medical nutrition therapy for patients with diabetes and/or kidney disease • Sexually transmitted infection screening and counseling • Tobacco use cessation counseling
Children (screenings and assessments based on age): • Screening for: o Autism o Blood pressure o Cervical dysplasia o Congenital hypothyroidism o Depression o Developmental issues o Dyslipidemia o Hearing o Hematocrit or hemoglobin o Hemoglobinopathies or sickle cell o HIV o Lead o Obesity (and counseling) o Phenylketonuria (PKU) o Vision • Assessment for: o Alcohol and drug use o Behavioral issues o Oral health • Fluoride chemoprevention supplements • Gonorrhea preventive medication for newborns • Height, weight, and BMI measurements • Immunizations for: o Diphtheria, pertussis, tetanus o Hepatitis A and B o HiB (Haemophilus influenza type b) o Human papillomavirus (HPV) o Inactivated poliovirus o Influenza (flu shot) o Measles, mumps, rubella o Meningococcal o Pneumococcal o Rotavirus o Varicella • Iron supplements • Medical history • Sexually transmitted infection prevention counseling and screening • Tuberculin testing
In addition to the services listed above, CMS is developing other initiatives to improve preventive services.
Preventive Care Programs Targeting Moms and Babies
Strong Start for Mothers and Babies A new public-private partnership aims to improve maternal and infant health outcomes, especially for those patients enrolled in Medicaid. "Strong Start" is a joint effort of CMS, the Health Resources and Services Administration (HRSA), the Administration on Children and Families (ACF), and outside groups including the March of Dimes, the American College of Obstetricians and Gynecologists (ACOG), the National Partnership for Women and Families, the Society for Maternal-Fetal Medicine, American College of Nurse Midwives, Childbirth Connection, Leapfrog Group, the National Priorities Partnership convened by the National Quality Forum, and others.[7,8] There are 2 components. The first is a nationwide awareness campaign to decrease the rate of elective deliveries before 39 weeks gestation. Currently elective deliveries before 39 weeks account for 10% to 15% of all deliveries.[7,8] The second component is an initiative to reduce the rate of preterm births among high-risk women covered by Medicaid through testing and disseminating best practices in prenatal care. The project will fund evidence-based approaches to providing enhanced prenatal care with the goal of improving birth outcomes for mother and baby.[7,8]
For more information on the Strong Start Campaign, visit innovation.cms.gov.
CMS and Text4Baby Partnership CMS is partnering with Text4Baby, a free national texting service in which users receive messages alerting them to the availability of free and low-cost health coverage through Medicaid and the Children's Health Insurance Program (CHIP). Pregnant women and new moms will receive text messages on such health issues as the importance of prenatal visits, well-child visits, and medical care for their children when they are sick. For more information on the CMS and Text4Baby initiative, visit HHS.gov.
Comprehensive Primary Care Initiative Targeting Clinicians
The Centers for Medicare & Medicaid Services (CMS) aims to help primary care clinicians provide high-quality, coordinated, and patient-centered care through the Comprehensive Primary Care Initiative (CPC). Working with commercial and state health insurance plans, CMS will offer bonus payments to primary care doctors who better coordinate care for their patients; clinicians will be offered the opportunity to share in the savings they generate after 2 years. In addition, participating clinicians will be given resources to assist them in care coordination. Through CPC, clinicians will be asked to: • Manage care for patients with serious or multiple medical conditions with a patient-centered approach • Ensure access to care 24/7 • Provide appropriate preventive care services • Engage patients and their families to be active participants in their care • Coordinate care "across medical neighborhoods," working with the patient's other healthcare providers in a team approach and utilizing electronic health records
For more information on the CPC initiative, visit innovation.cms.gov.
References 1. Sommers BD. Wilson L. ASPE Issue Brief. Fifty-four million additional Americans are receiving preventive services coverage without cost-sharing under the Affordable Care Act. US Department of Health & Human Services website. February 2012. http://aspe.hhs.gov/health/reports/2012/PreventiveServices/ib.shtml. Accessed March 2, 2012. 2. American Academy of Family Practitioners. Summary of recommendations for clinical preventive services. August 2011. http://www.aafp.org/online/etc/medialib/aafp_org/documents/clinical/CPS/rcps08-2005.Par.0001.File.tmp/August2011SCPS08152011.pdf. Accessed March 5, 2012. 3. Burton OM. AAP Press statement on HHS interim rule on preventive services. July 15, 2010. http://www.aap.org/en-us/about-the-aap/aap-press-room/pages/AAP-Press-Statement-on-HHS-Interim-Rule-on-Preventive-Services-.aspx. Accessed March 5, 2012. 4. Fact Sheet. US Department of Health and Human Services. Preventive services covered under the Affordable Care Act. http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html. Accessed March 2, 2012. 5. Medicare Preventive Services. US Department of Health and Human Services. February 2012. http://www.healthcare.gov/law/features/65-older/medicare-preventive-services/index.html. Accessed March 2, 2012. 6. Preventive Services. Medicare website. http://www.medicare.gov/navigation/manage-your-health/preventive-services/preventive-service-overview.aspx?AspxAutoDetectCookieSupport=1. Accessed March 2, 2012. 7. Strong Start for Mothers and Newborns. Center for Medicare & Medicaid Innovation website. http://www.innovation.cms.gov/initiatives/strong-start/. Accessed March 2, 2012. 8. Strong Start for Mothers and Newborns frequently asked questions. Center for Medicare & Medicaid Innovation website. http://www.innovation.cms.gov/initiatives/Strong-Start/Strong-Start-for-Mothers-and-Newborns-FAQ-page.html. Accessed March 2, 2012. 9. US Department of Health and Human Services (HHS). Obama Administration and Text4Baby join forces to connect pregnant women and children to health coverage and information. HHS website. February 2012. http://www.hhs.gov/news/press/2012pres/02/20120228c.html. Accessed March 2, 2012. 10. Fact Sheet. Comprehensive Primary Care Initiative. US Department of Health and Human Services. September 2011. http://www.innovation.cms.gov/FilRees/fact-sheet/Comprehensive-Primary-Care-Initiative-Fact-Sheet.pdf. Accessed March 2, 2012.
Written by Stacey J.P. Ullman, MHS, Scientific Director, Medscape, LLC, New York, NY and Jane Lowers, Senior Scientific Director, Medscape, LLC, New York, NY