Preventive Care Benefits Update (for non-grandfathered plans)
June 30, 2011

We recently updated our preventive care flyer to more clearly identify that only the listed services will be paid at 100% for members whose benefit plans are subject to the preventive care services under health care reform. Any services not on the list of guidelines are subject to regular plan benefits.

We also want to make you aware of some further updates regarding preventive care services:

Mammograms -

• Preventive mammograms meeting the USPSTF guidelines will be paid at 100% when provided at a facility or a physician’s office. Claims billed at a facility were originally paid incorrectly. Any impacted claims have been reprocessed.

Colonoscopies -

• There has been some confusion about this benefit regarding what is covered as a preventive care benefit.  Routine colonoscopies are paid at 100% if they meet the USPSTF screening guidelines. Any procedure performed due to a medical condition or any subsequent diagnostic colonoscopies are not considered routine preventive screenings and will be covered as a regular medical benefit.
• When a polyp is found during a screening, we will pay for the procedure (if available under reform), but the provider needs to bill certain codes. When the polyp is sent for a pathology test, the pathology test is normally considered diagnostic and standard lab benefits apply. If the lab bills the test with a preventive diagnosis code, it will be paid under the reform benefit (100%). In the majority of cases, labs will not know if the procedure is preventive or diagnostic.
• Based on further analysis of the USPSTF guidelines by Regence, screenings billed with certain family history codes for members under age 50 will now be covered at 100%.
• Provider training is ongoing to insure that physicians and labs apply the appropriate coding for both the colonoscopy and any associated lab tests. Members with questions on how their claim was processed can contact Customer Service.

Tobacco Cessation benefits -

• Health care reform now requires that Regence include “first dollar” preventive benefits for tobacco use counseling and interventions. Regence has determined that this will include treatment and pharmacotherapy benefits.  We will now cover prescriptions for generic tobacco cessation medications at 100%. See separate tobacco cessation communication sent previously here.  Our claims systems are in the process of being updated.  If a member is required to pay up front, they can send in the claim for reimbursement.

For Our Larger Groups -

• We are now allowing large groups 100+ the option of expanding the benefits that will be paid at 100% when billed with certain preventive diagnosis codes.  This option gives a group not only the preventive services limited by age and frequency as indicated in the USPSTF guidelines, but broader preventive care services.

The updated flyer, click here. If you have any questions, please contact your Sales team.

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