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Information for providers

Your patients have questions. Look to us for the answers.

The Affordable Care Act requires that most plans — both on and off of the Health Insurance Marketplace — cover a set of basic health services, as well as provide certain preventive services, at no cost to the consumer. Additionally, the ACA introduced a number of provider payment reforms aimed at increasing access for the newly covered population.

Covered services

Essential health benefits

The Affordable Care Act requires that health plans in the individual and small-group markets — both inside and outside the health insurance exchanges — include a core package of essential services. Essential health benefits must be equal in scope to the benefits covered by a typical employer plan and include items and services within at least the following 10 general categories:

  1. Ambulatory patient services
  2. Emergency services
  3. Hospitalization
  4. Maternity and newborn care
  5. Mental health and substance use disorder services, including behavioral health treatment
  6. Prescription drugs
  7. Rehabilitative and habilitative services and devices
  8. Laboratory services
  9. Preventive and wellness services and chronic disease management
  10. Pediatric services, including oral and vision care

Each state may set its own essential health benefit package based on a “base-benchmark plan,” which serves as the model package for all applicable plans in that state. Virginia’s base-benchmark plan is the Anthem Keycare 30 plan.

Preventive health services

The ACA requires all new plans to cover certain preventive services without charging a co‐pay or coinsurance. This applies only when these services are delivered by a network provider.

All adults
  • Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
  • Alcohol misuse screening and counseling
  • Aspirin use to prevent cardiovascular disease for men and women of certain ages
  • Blood pressure screening for all adults
  • Cholesterol screening for adults of certain ages or at higher risk
  • Colorectal cancer screening for adults over 50
  • Depression screening for adults
  • Diabetes (Type 2) screening for adults with high blood pressure
  • Diet counseling for adults at higher risk for chronic disease
  • HIV screening for everyone ages 15 to 65, and other ages at increased risk
  • Immunization vaccines for adults — doses, recommended ages and recommended populations vary
  • Obesity screening and counseling for all adults
  • Sexually transmitted infection prevention counseling for adults at higher risk
  • Syphilis screening for all adults at higher risk
  • Tobacco use screening for all adults and cessation interventions for tobacco users
Women
  • Anemia screening on a routine basis for pregnant women
  • Breast cancer genetic test counseling for women at higher risk for breast cancer
  • Breast cancer mammography screenings every one to two years for women over 40
  • Breast cancer chemoprevention counseling for women at higher risk
  • Breastfeeding comprehensive support and counseling from trained providers and access to breastfeeding supplies for pregnant and nursing women
  • Cervical cancer screening for sexually active women
  • Chlamydia infection screening for younger women and other women at higher risk
  • Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs) [This does not apply to health plans sponsored by certain exempt "religious employers”].
  • Domestic and interpersonal violence screening and counseling for all women
  • Folic acid supplements for women who may become pregnant
  • Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
  • Gonorrhea screening for all women at higher risk
  • Hepatitis B screening for pregnant women at their first prenatal visit
  • HIV screening and counseling for sexually active women
  • Human papillomavirus DNA test every three years for women with normal cytology results who are 30 or older
  • Osteoporosis screening for women over age 60 depending on risk factors
  • Rh-incompatibility screening for all pregnant women and follow-up testing for women at higher risk
  • Sexually transmitted infections counseling for sexually active women
  • Syphilis screening for all pregnant women or other women at increased risk
  • Tobacco use screening and interventions for all women and expanded counseling for pregnant tobacco users
  • Urinary tract or other infection screening for pregnant women
  • Well-woman visits to receive recommended services for women under 65
Children
  • Autism screening for children at 18 and 24 months
  • Behavioral assessments for children at the following ages: birth to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Blood pressure screening for children at the following ages: birth to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Cervical dysplasia screening for sexually active females
  • Depression screening for adolescents
  • Developmental screening for children under age 3
  • Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Fluoride chemoprevention supplements for children without fluoride in their water source
  • Gonorrhea preventive medication for the eyes of all newborns
  • Hearing screening for all newborns
  • Height, weight and body mass index measurements for children at the following ages: birth to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Hematocrit or hemoglobin screening for children
  • Hemoglobinopathies or sickle cell screening for newborns
  • HIV screening for adolescents at higher risk
  • Hypothyroidism screening for newborns
  • Immunization vaccines for children from birth to age 18 — doses, recommended ages and recommended populations vary
  • Iron supplements for children ages 6 to 12 months at risk for anemia
  • Lead screening for children at risk of exposure
  • Medical history for all children throughout development at the following ages: birth to 11 months, 1 to 4 years , 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Obesity screening and counseling
  • Oral health risk assessment for young children at the following ages: birth to 11 months, 1 to 4 years, 5 to 10 years
  • Phenylketonuria screening in newborns
  • Sexually transmitted infection prevention counseling and screening for adolescents at higher risk
  • Tuberculin testing for children at higher risk of tuberculosis at the following ages: birth to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
  • Vision screening for all children

Incentive payments for primary care services

Primary Care Incentive Payment Program (EXPIRED)

The ACA authorizes a 10 percent Medicare payment bonus from 2011 to 2015 for physicians who specialize in family medicine, internal medicine, geriatric medicine or pediatric medicine or for nurse practitioners, clinical nurse specialists and physician assistants for whom primary care services account for at least 60 percent of their Medicare-allowed charges.

Primary care practitioners are identified as:

  • Physicians enrolled in Medicare with a primary specialty designation of 08-family practice, 11-internal medicine, 37- pediatrics or 38-geriatrics; or
  • Non-physician practitioners enrolled in Medicare with a primary care specialty designation of 50-nurse practitioner, 89-certified clinical nurse specialist or 97-physician assistant

» Visit CMS.gov for more details on PCIP eligibility.

HPSA Surgical Incentive Payment (EXPIRED)

Effective Jan. 1, 2011, through Dec. 31, 2015, physicians serving in designated health professional shortage areas will receive an additional 10 percent bonus for major surgical procedures with a 10- or 90-day global period. This additional payment, referred to as the HPSA Surgical Incentive Payment, will be combined with the original HPSA payment and will be paid on a quarterly basis.

» Visit CMS.gov for more details on physician bonuses.

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Virginia Commonwealth University Medical Center Office of Health Innovation One Capitol Square, 23rd floor, Suite 2310 830 East Main Street Richmond, Virginia 23298-0622 Phone: (804) 828-8301 Fax: (804) 828-2118 Email: ohi@vcu.edu Updated: Created by University Relations