Provider Notice issued 12/31/14

Coverage of Preventive Services for Adults Age 19-64

The purpose of this notice is to clarify coverage and cost sharing provisions for preventive services for adults age 19-64 enrolled in Illinois Medical Assistance programs, when the purpose of the visit is preventive in nature. Cost sharing is the portion of the cost of medical care that enrollees pay themselves; more detail can be found in the Department of Healthcare and Family Services (HFS) Provider Handbook Chapter 100 Appendix 12 (pdf).

Pursuant to the Affordable Care Act, which modified Section 2713 of the Public Health Service Act, and the essential health benefit requirements that apply to Alternative Benefit Plans, HFS provides coverage without cost sharing for certain preventive services for adults 19-64:

• Evidence-based items or services that have in effect a rating of “A” or “B” in the current recommendations of the Unites States Preventive Services Task Force (USPSTF);

• Immunizations for routine use that have in effect a recommendation from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention;

• With respect to adolescents age 19-21, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Human Services Administration (pdf) (HRSA) to the extent not already included in USPSTF and ACIP recommendations; and

• With respect to women, evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA, to the extent not already included in USPSTF and ACIP recommendations.

HFS offers 100% coverage for the items and services above when the purpose of the visit is preventive in nature, limited to two preventive office visits without cost sharing per enrollee per year. HFS encourages efficient, patient-centered approaches to care delivery, such as age appropriate counseling, screenings, and tests at a single office visit.

In order for the department to recognize services available without cost sharing, providers should identify such services by using the appropriate procedure codes, diagnosis codes, and, when applicable, modifiers. Services rendered primarily for preventive purposes should be submitted using the age-appropriate preventive medicine evaluation and management service code. Services rendered for family planning purposes should be submitted using the appropriate modifier and diagnosis codes. Prenatal and postpartum services should be submitted using the appropriate diagnosis codes.

When preventive services are provided as part of a problem focused visit, cost sharing is permitted and will be applied to the claim by HFS. A preventive visit differs from a problem focused visit because its components are based on age and risk factors rather than a presenting problem.

HFS is making two changes to achieve compliance with the requirements outlined above:

• Effective January 1, 2015, HFS will cover aspirin tablets for the prevention of cardiovascular disease without cost sharing when prescribed in accordance with USPSTF guidelines.

• Effective January 1, 2015, HFS will cover folic acid tablets to prevent neural tube defects without cost sharing when prescribed in accordance with USPSTF guidelines.

Coverage without cost sharing of the items and services above are required for Alternative Benefit Plans in the Medicaid program. Because Illinois’ Alternative Benefit Plan for individuals in the ACA Adult eligibility category is fully aligned with its standard Medicaid benefit package, coverage without cost sharing for these items and services applies to all adults age 19-64 in Illinois Medical Assistance Programs.

Questions regarding this notice may be directed to the Bureau of Professional and Ancillary Services at 1-877-782-5565.

James M. Parker, Acting Administrator

Division of Medical Programs