Among the many provisions of health care reform legislation is a mandate to cover all preventive services at 100%. Although this provision does not go into effect for grandfathered plans until 2014, it already is in effect for nongrandfathered plans.
The list of preventive services that will need to be covered is available at: www.healthcare.gov/law/about/provisions/services/lists.html.
While it's easy to simply say that preventive care is covered at 100%, the actual administration of this benefit is exceedingly complex. Here are some common concerns and things you can do now to address them:
* Eligible expenses. Some items on the list of covered services are not currently covered under most medical plans, such as aspirin, fluoride and iron supplements. There is administrative complexity surrounding how to handle these items.
Should the individual get a prescription from their doctor, similar to the new flexible spending account rules? Do they just submit a claim for reimbursement? Is the insurer even willing to cover these items at all?
What to do: Provide the list of covered items to your insurer early and ask them about their plan to address these types of items. If they do not yet have a plan of action, request semi-annual updates on the status.
* Participant confusion. Finding a clear definition of the difference between preventive and routine care, and educating your participants, is also key.
Many services that a participant considers preventive are not, such as screening for skin cancer, follow-up care and colon cancer screenings for individuals under age 50.
Furthermore, insurers seem to have varying policies layered over the government's policies. One such example is insurers applying a policy that you cannot get an annual physical covered unless it has been 12 months or more since your last one. Confused participants mean extra work for you.
What to do: Get a clear policy from your insurer on how they administer preventive care benefits. Once you have an understanding, share this information broadly with your employees.
If you are self-insured, consider making further modifications to the plan to broaden the allowed items or remove any restrictions that make it administratively burdensome.
* Provider confusion. If your participants are confused, providers are even more in the dark when it comes to submitting claims for preventive services.
Specifically, if the first diagnosis code on the claim is not listed as preventive, most auto-adjudicated claims will process it as a regular claim and charge any applicable deductible, coinsurance or copayment.
The codes that visits are billed under are often tied to the primary issue that the patient states is the reason for the appointment. If a patient comes in for a medication refill and a physical, and the medical office writes it down in that order, it gets processed incorrectly. This results in lost productivity as your employees call to get their claims reprocessed.
What to do: Ask your insurer what their provider relations plan is for educating their doctors and office staff on the correct billing process for preventive care. Provide your employees with a quick script on what to say when they make an appointment or when they call the provider.
Have your insurer track and report on the number of claims that have been reprocessed due to a billing error and ask for intervention if there are specific providers that are continually making this mistake.
* Insurance carrier rules. The list created by the government is primarily drawn from the U.S. Preventive Services Task Force. However, many insurance companies overlay their own internal definitions of preventive care on this list. The insurance company definitions vary greatly company by company.
One example of this benefit overlay is mammogram coverage. USPSTF says that mammograms are not necessary for women under age 50. Most insurers cover mammograms for women 40 and up. There's not one easy list to which you can refer your participants or physicians to easily determine what is covered.
What to do: Request a list from your insurance company of the items considered preventive care and make this easily available internally to assist with minimizing confusion.
Contributing Editor Shana Sweeney is a benefits professional at Google. She has degrees in politics and human resources as well as her SPHR. She has over a decade of experience working in various industries, including high-tech, utilities, manufacturing, and health insurance. Additionally, she is a self-proclaimed geek and politics junkie.
In this article, the preventive care mandate was confused with the pre-existing condition exclusion removal mandate.
Grandfathered plans do not need to comply with the preventive care regulations as long as they maintain grandfathered status. However, according to Aon Hewitt, 90% companies anticipate losing grandfathered status by 2014.
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