We believe that a well-designed, evidence-based health maintenance program is important to the long-term health of our members. We follow the recommendations of the US Preventive Services Task Force (USPSTF) to determine what tests and examinations are appropriate as preventive or screening services. Also, we cover immunizations based on the recommendations of the Advisory Committee on Immunization Practices (ACIP) as interpreted in our immunization policies.
In addition to the standard wellness benefits, the federal Affordable Care Act (ACA) addresses preventive services. The preventive services component of the law became effective September 23, 2010. The law requires all “non-grandfathered” health plans to cover preventive medicine services given an “A” or “B” recommendation by USPSTF. For detailed information, see Preventive Health Benefit policy (BI062). However, if there are multiple equivalent testing options available to fulfill a USPSTF “A” or “B” recommendation (such as for colorectal cancer screening), less cost-effective options may not be covered.
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.
- Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
- Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.
- Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.
- Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
- Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
Those preventive services listed as Grade A and B recommendations are covered under preventive health benefits as specified in the member’s plan documents. Please note that it may take up to twelve (12) months following an A or B rating by the USPSTF for QualChoice to implement coverage as a preventive service. For most plans, these services will be covered without cost sharing (i.e., deductible, coinsurance or copayment) by health plans for services provided by an in-network provider (for these plans, preventive services are not covered if provided by an out-of-network provider). If the primary purpose for the office visit is other than a Grade A or B USPSTF preventive care service, then deductible, coinsurance or copayment may apply.
The ACA Grace Period for premium payments will directly affect your payment for services, and may impact how you run your practice. Read more on how QualChoice applies and implements the grace period.
The ACA requires that we share with providers the plan status of Marketplace members who are receiving a subsidy (Advanced Premium Tax Credit, or APTC).
Identifying Members in a Non-Payment Grace Period
Providers, both participating and non-participating with QualChoice, will be able to identify members in the grace period:
- Proactively through EDI 270/271 eligibility checks, which are available in as little as three seconds; these now include the paid-through date.
- Retroactively on the Remittance Advice
Determining the Grace Period
The total grace period for non-payment of premiums is three months. The ACA requires plans to pay claims for the first month of the premium grace period.
Processing Claims in the First Month of Non-payment
For the first month of premium non-payment, we will pay claims. The informational code V12 and description below on the Remittance Advice will notify you that the premium is not paid.
V12 (message, first month of grace period):
Alert: This enrollee is in the first month of the advance premium tax credit grace period
Processing Claims in the Second and Third Months
After the first month of non-payment of premium, we will process claims for $0 subject to automatic reprocessing if the premium is paid. You’ll see an indication on the RA that the claim was pended due to nonpayment of premium as opposed to “not payable.”
OPE (first line, second and third month of grace period):
The disposition of the claim is undetermined during the premium payment grace period, per Health Insurance Exchange requirement.
V13 (message, second and third month of grace period):
Alert: This claim will automatically be reprocessed if the enrollee pays their premiums.
Reminder: Contracted providers should continue to bill QualChoice until member liability or disposition is established.
For questions, contact your Provider Network Territory Map.