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Healthcare Reform Act

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Details:

The wellness services included in the law are those mandated by the United States Preventive Services Task Force (USPSTF), Centers for Disease Control (CDC) and Health Resources and Services Administration (HRSA).
• The USPSTF recommendations are for the preventive services rated A or B and cover a broad range of services such as mammograms, screening for various diseases and conditions (e.g., high blood pressure, high cholesterol and diabetes) and counseling for certain issues (e.g., obesity, smoking cessation and diet).
• The CDC recommends an immunization schedule for infants through adults.
• The HRSA recommends wellness services for infancy through age 21, including well-child visits and various screenings.
• The HRSA anticipates it will publish wellness recommendations for women in August 2011.

Visit www.uspreventiveservicestaskforce.org and click the link under Recommendations and then the Affordable Care Act link for additional preventive care recommendations of the USPSTF.

What does it mean?
When you use a participating network provider for these services, cost-sharing requirements, such as your responsibility to pay your deductible, coinsurance and co-pays will not be required for specific benefits under reform. Sometimes the term “first-dollar” is used for this type of coverage and means the plan pays these
certain benefits 100% — without any payment from you. However, if you use a non-network provider (i.e., you go outside of your network) for these services, the cost-sharing requirements of the plan will apply.

What is and isn’t included?
While a number of diagnostic tests and screenings are part of the wellness services benefits, other charges related to those services, such as office visits and physician fees, may not be. The carrier will need to review what the provider submits as the purpose of the visit, as well as the type of services received, to determine if the office visit will be covered as a first-dollar benefit.
Sample of services included:
-Annual mammograms for women 40 and over
-Annual Pap tests for women
-Child immunizations to age 21
-Well-baby and well-child visits to age 21
-Routine colonoscopy for adults 50 and over
-Office visits for the purpose of preventive screenings included in the law

Preventive/wellness benefits 

To help you proactively maintain your health, and small group major medical
plans effective March 24, 2010, and later include preventive care benefits defined by the Patient Protection and Affordable Care Act (health care reform law). When you use a participating network provider, eligible preventive services will be covered without you paying any deductible, coinsurance or copay!
Covered preventive services for adults
All adults — immunizations
Hepatitis A
Hepatitis B
Human papillomavirus (HPV)
Influenza
Measles, mumps and rubella
Meningococcal (meningitis)
Pneumococcal (pneumonia)
Tetanus, diphtheria, pertussis
(whooping cough)
Varicella (chicken pox)
Zoster (shingles)
All adults — screenings and counseling
Alcohol misuse screening and counseling

Blood Pressure Screening

Colorectal cancer screening for adults age 50-75 Depression screening
Type 2 diabetes screening for adults with elevated blood pressure
Healthy diet counseling (behavioral dietary counseling for adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic diseases)
HIV screening for adults at increased risk
Obesity screening, counseling and behavioral interventions
STI counseling (behavioral counseling to prevent sexually transmitted infections) for adults at high risk
Tobacco use counseling and cessation interventions
Syphilis screening for individuals at increased risk
Men — additional screenings and counseling
Aspirin for prevention of certain cardiovascular diseases for men age 45-79
Abdominal aortic aneurysm screening for
men age 65-75 who have ever smoked
Lipid disorders screening for specific ages or at increased risk
Women — additional screenings and counseling
Aspirin for prevention of certain cardiovascular diseases for women age 55-79
Genetic counseling for women at increased risk for the BRCA genetic mutation
Counseling on chemoprevention for women at high risk for breast cancer
Breast cancer screening via mammography for women age 40 and older
Cervical cancer screening via Pap smear
Chlamydia infection screening
Folic acid supplementation
Gonorrhea screening for women at high risk
Lipid disorders screening for women of specific ages and at increased risk
Osteoporosis screening for women age 60 and older, depending on risk factors for osteoporotic fractures
All children — immunizations
Diphtheria, tetanus, pertussis
Haemophilus influenza type B
Hepatitis A
Hepatitis B
Human papillomavirus for females
age 9 and older
Inactivated poliovirus
Influenza
Measles, mumps and rubella
Meningococcal (meningitis)
Pneumococcal (pneumonia)
Rotavirus
Varicella (chicken pox)
Children and adolescents — screenings and counseling
Oral fluoride supplementation for children age
6 months to 5 years when the primary water source is deficient in fluoride
HIV screening for adolescents at increased risk
Major depressive disorder screening for adolescents age 12-18
Iron supplementation for children age
6 months to 1 year who are at increased risk for iron deficiency anemia
Obesity screening and behavioral interventions for children age 6 and older
STI counseling (behavioral counseling to
prevent sexually transmitted infections) for adolescents at high risk
Syphilis screening for adolescents at increased risk
Visual impairment screening for children under age 5
Newborn infants — screenings
Biotinidase deficiency
Congenital adrenal hyperplasia
Congenital hypothyroidism
Galactosemia
Gonorrhea prophylactic medication
Hearing loss
Homocystinuria
Maple syrup urine disease
Medium chain acyl-CoA dehydrogenase
(MCAD) deficiency
Organic acid disorders
Other fatty acid oxidation disorders
Phenylketonuria
Sickle cell disease
Urea cycle disorders
Pregnant women — additional screenings and counseling
Alcohol misuse screening and counseling
Anemia screening
Bacteriuria screening
Breastfeeding counseling
Chlamydia infection screening
Gonorrhea screening for women at high risk
Hepatitis B screening
Rh incompatibility screening
Tobacco use counseling
Syphilis screening
How your plan pays for preventive services:
Benefits are determined by the procedures and procedure codes submitted to us by your health care provider. When you use a participating networkprovider, eligible preventive services will be covered and you will not pay a deductible, coinsurance or copay. However, some charges related to covered preventive services, such as office visits and physician fees, may not be considered preventive benefits.
Services intended to diagnose, treat or monitor an illness or injury are not considered preventive, so your plan deductible, coinsurance
and copays may apply.
How the guidelines were developed
The wellness services included are mandated by the United States Preventive Services Task Force (USPSTF), Centers for Disease Control
(CDC) and Health Resources and Services Administration (HRSA). Visit www.uspreventiveservicestaskforce.org and click “Recommendations,” then “Affordable Care Act” for additional USPSTF recommendations. For more information, please go to www.uspreventiveservicestaskforce.org.
Excluded plans
100% coverage of these preventive services does not apply to  Short Term Medical plans, nor does it apply
to most “grandfathered” plans (those with effective dates on or before March 23, 2010). Excluded plans may offer different preventive services benefits.

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