Coverage of Preventive Services

by Valerie A. Rinkle, MPA, regulatory specialist for HCPro

One provision of the Affordable Care Act (ACA) was new discretionary authority given to CMS to authorize Medicare coverage of additional preventive services. This expanded authority has the ability to change the model of the Medicare program from an indemnity medical insurance program to more of a full-fledged health insurance program. Recall that, by statute, services may only be covered and payable by standard or fee-for-service Medicare when they are "reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member". Therefore, up until the ACA granted this new authority, it took an act of Congress to explicitly provide statutory authority for preventive services such as mammograms, prostate screenings, and colonoscopy tests in the absence of other statutory authorization for payment.

On February 5, CMS announced coverage of HIV screening under this new authority.  Similar to when CMS announced coverage of low dose CTs for lung cancer, this policy is retroactive to April 13, 2015, and has several implementation dates spanning from March 7, 2016, through January 3, 2017, based on the type of provider or supplier and the various contractor system updates necessary to process claims. The NCD is R190NCD and the implementing transmittal is R3461CP. 

Previously, the USPSTF recommended screening for adolescents and adults at increased risk for HIV infection, as well as all pregnant women. The USPSTF made no recommendation for or against routine HIV screening for those not in a risk category. However, as of April 2013, the USPSTF updated their recommendations for HIV infection screening of adolescents and adults aged 15 to 65 years. Younger adolescents and older adults who are at increased risk should also be screened. The USPSTF also recommends that clinicians screen all pregnant women for HIV, including those who present in labor who are untested and whose HIV status is unknown. These recommendations are Grade A recommendations from the USPSTF.

Also on February 5, CMS announced coverage of screening for cervical cancer with Human Papillomavirus (HPV) Testing. As with the HIV testing policy, this policy is retroactive to July 9, 2015, and has several implementation dates spanning from March 7, 2016, through January 3, 2017, based on the type of provider or supplier and the various contractor system updates necessary to process claims. The NCD is R189NCD and the implementing transmittal is R3460CP.

R3460CP explains that CMS determined that the evidence is sufficient to add HPV testing once every five years as an additional preventive service benefit under the Medicare program. This preventive benefit is for asymptomatic beneficiaries aged 30 to 65 years in conjunction with a pap smear test. CMS will cover screening for cervical cancer with the appropriate FDA-approved/cleared laboratory tests, used consistently with FDA-approved labeling, and in compliance with the CLIA regulations.

To view the complete article that appeared on Medical Compliance Watch, click here.