Health Information Management

Q/A: Copays for preventive services

APCs Insider, June 3, 2011

Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

Q: How does healthcare reform affect copayments for preventive services?

A: President Barack Obama signed two significant statutes into law last year. The Patient Protection and Affordable Care Act, Public Law 111-148, and the Health Care and Education Reconciliation Act of 2010, Public Law 111-152,, attempt to change the nature and culture of modern healthcare. Collectively they are known as the Affordable Care Act (ACA).

The ACA broadens Medicare coverage for preventive services. It requires Medicare to pay 100% of the cost of preventive services recommended by the U.S. Preventive Services Task Force (USPSTF), which uses a letter grading system to determine when a service is appropriate.

These provisions waive any deductible or coinsurance payment for wellness visits and most preventive items and services. Examples include bone mass measurement, colorectal cancer screening, influenza and pneumococcal vaccines, and ultrasound abdominal aortic aneurysm screening.

The USPSTF updated its definitions of the letter grades it assigns to include recommendations and "suggestions for practice" for each grade. It also has defined levels of certainty regarding net benefit.

These definitions apply to USPSTF recommendations voted on after May 2007:.

  • A—USPSTF recommends this service. A high certainty that the net benefit is substantial exists. Suggestion: Offer or provide this service.
  • B—USPSTF recommends this service. A high certainty that the net benefit is moderate or a moderate certainty that the net benefit is moderate to substantial exists. Suggestion: Offer or provide this service.
  • C—USPSTF recommends against routinely providing the service. Considerations that support providing the service to an individual patient may exist. At least moderate certainty that the net benefit is small exists. Suggestion: Offer or provide this service only if other considerations support offering or providing the service to an individual patient.
  • D—USPSTF recommends against providing the service. A moderate or high certainty that the service has no net benefit or that the harm outweigh the benefits exists. Suggestion: Discourage the use of this service.
  • I—USPSTF concludes that the current evidence is insufficient to assess the balance the harm and benefits of the service. Evidence is lacking, of poor quality, or conflicting, making it impossible to determine the balance of benefits and harm. Suggestion: Read the clinical considerations section of USPSTF Recommendation Statement. If the service is offered, patients should understand the uncertainty that exists with respect to the balance of benefits and harm.

Some preventive services do not meet the criteria for waiver of deductible and coinsurance payments. The following preventive services continue to be subject to deductible and coinsurance payments because no statutory provision exempts them:

  • Digital rectal examination provided as a prostate cancer screening service (HCPCS Level II code G0102)
  • Glaucoma screening (CPCS Level II codes G0117 and G0118)
  • Diabetes outpatient self-management training (DSMT) services
  • Electrocardiogram, routine ECG with 12 leads; tracing only, without interpretation and report, performed as a screening for the initial preventive physical examination (HCPCS Level II code G0404)

References:

http://www.cms.gov/Transmittals/downloads/R739OTN.pdf
http://www.cms.gov/MLNMattersArticles/downloads/MM7012.pdf
http://www.healthcare.gov/law/provisions/preventive/index.html

Editor’s note: Andrea Clark, RHIA, CCS, CPCH, president of Health Revenue Assurance Associates, Inc., in Plantation, FL, answered this question.



Want to receive articles like this one in your inbox? Subscribe to APCs Insider!

Most Popular