New Year, New Health Benefits

AAFP Details ACA's 2014 Preventive Services; Offers Clinical, Coding Resources

January 07, 2014 02:10 pm News Staff

If you haven't made a new year's resolution yet, here's one you might want to think about: Make sure your patients get all the new preventive services they're entitled to under the Patient Protection and Affordable Care Act. As of Jan. 1, the ACA requires insurance plans to cover a wide range of clinical preventive services without any cost-sharing measures, such as copays or coinsurance.

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What's even better is that the AAFP is providing resources to help educate your patients -- and you -- about the new benefits, along with coding information that should make getting paid for providing the services a sure thing.

In the broadest of terms, there are two key points to keep in mind:

Visit for a comprehensive breakdown of covered services for adults(, women( and children(

Story highlights
  • Jan. 1 marked the introduction of mandatory coverage for numerous preventive care services among both publicly and privately insured patients in accordance with the Patient Protection and Affordable Care Act.
  • The AAFP has created an online resource that outlines many of these new benefits.
  • The Academy's Web page also provides clinical and coding information related to three key health issues -- obesity, tobacco cessation and immunizations -- addressed by the Affordable Care Act.

For family physicians, three major health issues stand out when it come to these covered services: obesity, tobacco cessation and immunizations.

Obesity and Fitness

According to the CDC(, the past two decades have seen a dramatic increase in obesity among U.S. adults, children and teens. The agency now estimates that more than one-third of U.S. adults are obese, as are nearly one in five children and adolescents ages 2-19. And it's not just a U.S. phenomenon; a report issued Jan. 3 by the Overseas Development Institute( stated that 34 percent of adults worldwide now are overweight or obese, thanks, in large part, to rapidly rising rates in developing countries such as Egypt and Mexico.

In an effort to stave off the myriad known ill effects of overweight and obesity, CMS announced in November 2011 that, in accordance with the ACA, Medicare would begin covering obesity preventive services for beneficiaries with no cost-sharing requirements. Specifically, that coverage includes:

  • screening for obesity by measuring body mass index (BMI),
  • providing dietary/nutritional assessment for patients whose BMI measures 30 kg/m2 or higher, and
  • providing these patients with intensive behavioral counseling and behavioral therapy to promote sustained weight loss through diet and exercise.

Patients must meet certain criteria to maintain eligibility for the intervention, and Medicare covers a maximum of 22 face-to-face sessions during a 12-month period.

As of Jan. 1, all private insurers also are required to cover intensive behavioral therapy counseling for obesity in adults, and screening and counseling must be covered with no cost-sharing by patients. Health plans will vary in which services they'll cover (e.g., telephone counseling, group visits, visits with a health coach), however, so patients and physicians should confirm specific benefits information beforehand.

Cessation of Tobacco Use

The AAFP has long had a stake in helping its members assist patients who want to quit smoking, as well as in helping keep patients from starting in the first place. As of Jan. 1, 2011, Medicare began covering tobacco cessation counseling for all its beneficiaries at no cost to them.

That coverage includes two levels of tobacco cessation counseling: intermediate and intensive. Evidence-based tobacco cessation counseling is a covered service, and Medicare Part D covers FDA-approved tobacco cessation drug therapies. However, OTC therapies typically are not covered.

Download Ask and Act Resources

Of the 46 million people in the United States who currently smoke, 70 percent say they would like to quit. Strong evidence indicates that advice from a health care professional can more than double a patient's chance of successfully quitting.

The AAFP's Ask and Act tobacco cessation program gives you resources designed to make your interventions with patients who use tobacco even more effective. Check out the Ask and Act Practice Resources page for up-to-date information on how to conduct and bill for group visits for would-be nonsmokers; a guide to pharmacotherapies that can help these patients stop using tobacco; lists of the latest Healthcare Common Procedure Coding System, CPT and ICD-9 codes related to tobacco cessation counseling; and more.

Medicare will cover two cessation attempts per year, with each attempt including a maximum of four intermediate or intensive counseling sessions. Thus, the total annual benefit covers as many as eight smoking/tobacco-use cessation counseling sessions during a 12-month period. Patients may receive another eight counseling sessions during a second or subsequent year as long as 11 months have passed since the first Medicare-covered cessation counseling session.

Also as of Jan. 1, all state Medicaid programs were required to support all FDA-approved smoking cessation medications without requiring copays or other financial barriers. In addition, many states offer some payment for individual tobacco cessation and treatment counseling, but health care professionals are encouraged to contact their state Medicaid office regarding specific coverage in their state.

As for private insurers, they are required to provide evidence-based tobacco cessation counseling and interventions to all adults and to pregnant women. Again, however, clinicians should check with individual insurance plans to determine which specific interventions are included and to what extent they are covered.

Vaccines and Immunizations

Each year, the AAFP and ACIP collaborate to develop recommendations for routine use of vaccines in children, adolescents and adults in the United States. As noted above, the ACA mandates coverage of all ACIP-recommended immunizations with no cost-sharing, although specific age ranges and patient subpopulations eligible for vaccination vary. The covered vaccines are

  • hepatitis A;
  • hepatitis B;
  • herpes zoster;
  • human papillomavirus;
  • influenza (seasonal);
  • measles, mumps and rubella;
  • meningococcal;
  • pneumococcal;
  • tetanus, diphtheria and pertussis; and
  • varicella.

Information about the specific diseases these vaccines prevent( is available from HHS' website.

As always, the AAFP provides you ready access to the annual recommended immunization schedules for patients of all ages. The Academy also puts information about coding for vaccine administration at your fingertips.