Coverage of PrEP
Certain preventive care services must be offered by health insurance companies and non-grandfathered group health plans without any cost-sharing obligations under the Affordable Care Act (ACA). The United States Preventive Services Task Force (USPSTF) and other agencies and advisory groups recommendations form the basis of the list of preventive care services. If a preventive care service or item requirement omits information on the frequency, manner, treatment, or setting to administer the preventive care service, plans and carriers are permitted to employ reasonable medical management practices.
Coding and Claims Management
Plans and carriers are also reminded by FAQ 68 of the significance of correctly coding claims for preventive care or services. Unless there is specific information to show that the care or service was not preventive care, items or services that are of a preventative care nature should be appropriately classified and processed without cost-sharing. In accordance with ERISA’s internal appeal and review rules, participants, beneficiaries, or enrollees contest an unfavorable benefit determination.
Have Questions? and want to read more about the changes FAQ 68 Addresses Preventive Care and Mastectomy Coverage for more details.
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