Preventive care is a cornerstone of maintaining good health, and understanding how healthcare reform impacts access to these vital services is crucial. Blue Cross and Blue Shield of North Carolina (BCBSNC) is committed to ensuring its members receive comprehensive preventive care coverage as mandated by the Patient Protection and Affordable Care Act (ACA). This guide provides a detailed overview of BCBSNC’s preventive services policy, focusing on coding guidelines and key aspects of healthcare reform that affect coverage.
Understanding Healthcare Reform and Preventive Services
The landmark Patient Protection and Affordable Care Act (ACA), enacted in March 2010, brought significant changes to the healthcare landscape in the United States. A key component of the ACA is its emphasis on preventive care. Recognizing the long-term benefits of early detection and prevention, the ACA requires most health insurance plans to cover a range of preventive services without cost-sharing. This means that for many plans, services like annual check-ups, vaccinations, and certain screenings are available at no additional out-of-pocket cost to the patient when delivered by in-network providers.
The ACA distinguishes between “grandfathered” and “non-grandfathered” health plans. Non-grandfathered plans, which are plans created or significantly changed after the ACA was enacted, are subject to these preventive services coverage requirements. BCBSNC is dedicated to adhering to these regulations for its non-grandfathered plans, ensuring members have access to essential preventive care.
Defining “Recommended Preventive Services”
The ACA outlines specific categories of preventive services that must be covered. These are broadly defined as “Recommended Preventive Services” and include:
- Evidence-based services with an “A” or “B” rating from the United States Preventive Services Task Force (USPSTF): The USPSTF is an independent panel of experts that rigorously reviews scientific evidence and assigns grades to preventive services based on their effectiveness. Services receiving an “A” or “B” rating are considered highly recommended.
- Immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) at the Centers for Disease Control and Prevention (CDC): The ACIP develops recommendations for vaccine usage in the civilian population in the United States. These recommendations cover immunizations for children, adolescents, and adults.
- Preventive care and screenings for infants, children, and adolescents supported by the Health Resources and Services Administration (HRSA): HRSA supports guidelines like the Bright Futures Periodicity Schedule and recommendations from the Uniform Panel of the Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children. These guidelines ensure comprehensive preventive care from birth through adolescence.
- Preventive care and screenings for women supported by the Health Resources and Services Administration (HRSA): These guidelines, initially based on recommendations from the Institute of Medicine, address the unique preventive health needs of women across their lifespan.
BCBSNC’s Commitment to Preventive Services Coverage
BCBSNC is dedicated to providing its members with access to these “Recommended Preventive Services” in accordance with ACA guidelines. For non-grandfathered plans, this means:
- In-network coverage: Preventive services are fully covered when received from providers within the BCBSNC network.
- No cost-sharing: Members will not be charged co-pays, co-insurance, or deductibles for these covered preventive services when received in-network.
This commitment ensures that financial barriers are removed, encouraging members to proactively engage in preventive healthcare. It’s important to note that while BCBSNC fully covers these specific “Recommended Preventive Services,” additional preventive services beyond these guidelines may be subject to standard cost-sharing. Furthermore, coverage without cost-sharing is specifically mandated for in-network providers. Out-of-network preventive care may have different coverage rules and cost-sharing implications.
Coding for Preventive Services with BCBSNC: Modifier 33
Accurate coding is essential for ensuring claims for preventive services are processed correctly and that members receive the benefits they are entitled to under healthcare reform. BCBSNC follows specific coding guidelines to identify and process preventive care claims.
A key coding element for preventive services is Modifier 33. This modifier is used in Current Procedural Terminology (CPT) coding to indicate that a service is preventive. According to CPT guidelines, Modifier 33 should be appended to a service code when:
- The primary purpose of the service is the delivery of an evidence-based service that is recommended with an “A” or “B” rating by the USPSTF.
- The service is another preventive service identified in preventive services mandates, whether legislative or regulatory.
Using Modifier 33 signals to BCBSNC that the service being billed is a covered preventive service under healthcare reform and should be processed without cost-sharing for eligible members and plans.
Referencing the BCBSNC Preventive Care Services Coding Document
For detailed and up-to-date coding requirements, providers should always refer to the dedicated BCBSNC Healthcare Reform Preventive Care Services Coding document. This document provides specific coding instructions, including appropriate CPT codes, HCPCS codes, and ICD-10 diagnosis codes that are relevant to preventive services. Staying informed about the latest coding guidelines ensures accurate claim submissions and smooth processing.
Key Considerations for Providers and BCBSNC Members
Navigating preventive care coverage and coding requires attention to several key points:
- Grandfathered vs. Non-Grandfathered Plans: The preventive services mandates of the ACA primarily apply to non-grandfathered plans. Grandfathered plans may have different coverage rules. Understanding your plan type is important.
- In-Network vs. Out-of-Network Providers: Cost-sharing waivers for “Recommended Preventive Services” apply specifically to in-network providers. Utilizing in-network providers ensures maximum coverage benefits.
- Office Visit Cost-Sharing: While the preventive service itself is covered without cost-sharing, the rules regarding office visit cost-sharing can be nuanced. If a preventive service is billed separately from an office visit, a cost-share may apply to the office visit. However, if the primary purpose of the visit is the preventive service and it’s not billed separately, cost-sharing should not apply to the office visit. Clarity in billing and coding is essential.
- Medical Management Techniques: BCBSNC, like other payers, may employ reasonable medical management techniques to determine the frequency, treatment, or setting for a preventive service, provided these are not explicitly specified in the USPSTF, ACIP, or HRSA guidelines.
Conclusion: Empowering Health through Preventive Care
Healthcare reform has significantly expanded access to essential preventive services, and BCBSNC is committed to fully implementing these provisions for its members. By understanding the scope of “Recommended Preventive Services,” coding guidelines like Modifier 33, and the nuances of in-network coverage and cost-sharing, both providers and BCBSNC members can effectively utilize these benefits. Prioritizing preventive care is an investment in long-term health and well-being, and BCBSNC is here to support its members on this journey. For the most detailed and current information, always consult the official BCBSNC resources and the Healthcare Reform Preventive Care Services Coding document.
References:
- American Academy of Pediatrics. Bright Futures: Coding for Pediatric Preventive Care Booklet, 2022. www.downloads.aap.org/AAP/PDF/Coding%20Preventive%20Care.pdf
- American Academy of Pediatrics/Bright Futures. Recommendations for Preventive Pediatric Health Care. American Academy of Pediatrics. www.aap.org/en/practice-management/care-delivery-approaches/periodicity-schedule/
- Advisory Committee on Heritable Disorders in Newborns and Children. Recommended Uniform Screening Panel. www.hrsa.gov/advisory-committees/heritable-disorders/rusp/index.html
- Advisory Committee on Immunization Practices (ACIP) Recommendations. www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/index.html
- Centers for Disease Control (CDC). Immunization Schedules. Vaccines and Immunizations, www.cdc.gov/vaccines/recs/schedules/default.htm.
- Healthcare.gov. Preventive care benefits for adults. www.healthcare.gov/preventive-care-adults/
- Healthcare.gov. Preventive care benefits for children. www.healthcare.gov/preventive-care-children/
- Healthcare.gov. Preventive care benefits for women. www.healthcare.gov/preventive-care-women/
- Institute of Medicine. Clinical Preventive Services for Women-Closing the Gaps. 2011. www.nap.edu/read/13181/chapter/1#iii
- 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.
- U.S. Preventive Services Task Force (USPSTF). Recommendations. www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics
- Women’s Preventive Services Guidelines (HRSA). www.hrsa.gov/womens-guidelines
- Women’s Preventive Services Initiative (WPSI). www.womenspreventivehealth.org/recommendations
