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Preventive Care Benefits Due to Health Care Reform – Updated May 2011

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The new health care reform law (the Patient Protection and Affordable Care Act or “PPACA”) requires Empire to cover additional preventive care services and eliminate member cost-sharing (copayments, deductibles, or coinsurance) for certain in-network preventive care services. Cost-sharing requirements for preventive care services rendered out-of-network continue to apply to member benefits. 
In general, changes in preventive care benefits for group health plans and group insurance policies administered or issued by Empire became effective on the group policy’s renewal date on or after September 23, 2010. The changes were effective for individual policies on the first policy year date on or after September 23, 2010, which in almost all cases was January 1, 2011. There are some exceptions to these dates, and not all plans are subject to the new preventive care coverage requirements, so providers should continue to verify eligibility and benefits through their normal business processes.  
To identify changes needed to comply with PPACA, we compared our current Preventive Care Guidelines and code list to the PPACA guidance provided by the U.S. Department of Health and Human Services (HHS). Most of the required screenings, immunizations, and exam services were already included in our Preventive Care Guidelines. However, certain services were added to our Preventive Care Guidelines, and those additional services are now covered as preventive care services with no member cost-share when rendered in-network. Newly-added services included several additional screening tests, counseling-related intervention services, and certain services associated with previously-covered screenings and vaccines whose scope of coverage has been expanded. Additionally, some services on our Preventive Care list are not among those required by PPACA. 
The list below provides an overview of services covered under our updated Preventive Care Guidelines. To understand the scope and details of the preventive care recommendations on which these changes were based, please refer to materials at the following link:  
Please note that the preventive services below are not recommended for all individuals, and medical necessity criteria may be applied. 
 
Child Preventive Care (Birth to 18 years) 
Preventive physical exams
Screening tests, assessments, and counseling including:

Newborn screenings

Vision screening

Hearing screening

Developmental and behavioral assessments

Oral health assessment

Screening for lead exposure

Hemoglobin or Hematocrit (blood count)

Blood pressure

Height, Weight, Body Mass Index (BMI)

Cholesterol and lipid level screening

Screening for depression

Screening and counseling for obesity

Behavioral counseling to promote a healthy diet

Screening for sexually transmitted infections

Pelvic exam and Pap test, including screening for cervical cancer

 
Immunizations including:

Hepatitis A

Hepatitis B

Diphtheria, tetanus, pertussis

Varicella (chicken pox)

Influenza (flu)

Pneumococcal (pneumonia)

Human papillomavirus (HPV)

Haemophilus Influenza type b (Hib)

Polio

Measles, Mumps, Rubella (MMR)

Meningococcal (meningitis)

Rotavirus

 
Adult Preventive Care (19 years and Older) 
Preventive physical exams
Screening tests including:

Eye chart vision screening

Hearing screening

Cholesterol and lipid level screening

Blood pressure

Height, Weight, Body Mass Index (BMI)

Diabetes screening

Prostate cancer screening, including digital rectal exam and PSA test

Breast cancer screening, including exam and mammography

Pelvic exam and Pap test, including screening for cervical cancer

Screening for sexually transmitted infections

HIV screening

Bone density test to screen for osteoporosis

Colorectal cancer screening including fecal occult blood test, barium enema, flexible sigmoidoscopy, screening colonoscopy, and CT colonography (as appropriate)

Aortic aneurysm screening (men)

Screenings during pregnancy including, but not limited to:

Hepatitis

Asymptomatic bacteriuria

Rh incompatibility

Syphilis

Iron deficiency anemia

Gonorrhea

Chlamydia

HIV

Screening and intervention services (including counseling and education) for:

Screening and counseling for obesity

Genetic counseling for women with a family history of breast and/or ovarian cancer

Behavioral counseling to promote a healthy diet

Primary care intervention to promote breastfeeding

Counseling related to aspirin use for the prevention of cardiovascular disease

Screening and behavioral counseling related to tobacco use and tobacco-caused disease

Screening and behavioral counseling related to alcohol misuse

 
Immunizations Including:

Hepatitis A

Hepatitis B

Diphtheria, tetanus, pertussis

Varicella (chicken pox)

Influenza (flu)

Pneumococcal (pneumonia)

Human Papilloma Virus (HPV)

Measles, Mumps, Rubella (MMR)

Meningococcal (meningitis)

Zoster (shingles)

 
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