Fall 2023
Aflac Survey Finds That Many Adults in the US are Skipping Wellness and Preventive Screenings. Here are the top Avoided Screenings:
Pap Smear
31%
Blood Testing
28%
Mammogram
26%
Colonoscopy
25%
Skin Cancer Exam
20%
STD Screening
18%
Annual wellness screenings are critical when it comes to the early identification of conditions. The Patient Protection and Affordable Care Act (PPACA) and the Health Care and Education Reconciliation Act of 2010 (HCERA) requires coverage of services, medications, and immunizations designated as “preventive care” and are available at no cost-sharing. Medical recommendations for preventive care are continually reviewed and revised, so covered services, medications, or immunizations may change from time to time.
Click on the link below for TPSC’s current Preventive Services list.
The Wagner Law Group Dives into A Recent Case Involving Emergency Services and Plan Exclusions
A recent U.S. Court of Appeals case ruled that a group health plan does not have to pay for emergency services specifically excluded by the plan document, but a deeper dive into the case reveals that it wasn’t the specific emergency service that was excluded. Instead, it was a procedure tacked on after the emergency service was completed.
Where Members Go for Care Matters
HealthQuest Publishers has released new data showing that where members receive care can have a big impact on employer health spend. Pricing for the same ICD-10 descriptions can vary drastically depending on where care is received.
Price Comparison: Retail Clinic, Urgent Care, Physician Office, & Hospital Outpatient (2023)
Average Charge Per Claim for Some Common Retail Clinic Diagnoses, by Sites of Care
| ICD-10 Description | Retail Clinic | Urgent Care | Physician Office | Hospital Outpatient |
|---|---|---|---|---|
| Encounter for immunization |
$104 | $154 | $241 | $379 |
| Type 2 diabetes mellitus without complications | $160 | $239 | $367 | $505 |
| Chronic kidney disease |
$255 | $263 | $639 | $1,325 |
| Chronic obstructive pulmonary disease, unspecified | $491 | $287 | $883 | $978 |
When you partner with TPSC for your self-funded plan, we ensure strategic partnership with local and national networks, so your employees have convenient access to affordable care when they need it.
Preventive Services, Private Health Plans, and the Affordable Care Act (ACA)
KFF published an updated article with current information on preventative services covered by private health plans under the Affordable Care Act. This includes requirements, preventative services summaries, coverage rules and clarifications, and studies conducted on the impact of the preventative services rule. Read the full article below.
New Cardiovascular Care Value Program for Clients With SafeGuardRx®
Did you know that heart failure accounts for about 85% of all heart disease deaths in the U.S.?1 Heart failure is a serious, life-threatening condition affecting approximately 6.5 million Americans over the age of 20.1 Due to these alarming numbers, the SafeGuardRx® Cardiovascular Care Value® program is expanding to offer new benefits for members with heart failure. Beginning May 1, 2023, clients using ESI for PBM services have access to these enhancements in addition to existing program benefits:
Expanded Therapeutic Resource CenterSM (TRC) support for patients taking a select heart failure medication by adding to our already robust TRC support. TRC member check-ins will monitor progress and can improve adherence and reduce abandonment.
New provider outreach for high-risk patients taking a select heart failure medication who may benefit from additional therapies.
Financial protection through an early discontinuation reimbursement for participating Cardiovascular Care Value preferred products.*
1. Heart Failure Society of America
* Early discontinuation credits are for select heart failure medication and only apply if your plan isn’t already receiving them in another program (ex. Diabetes Care Value program).
Notice for Clients With First Choice EAP: First Choice Health is Partnering With The Holman Group
First Choice Health has entered into a strategic partnership with The Holman Group, a California-based Employee Assistance Program (EAP) to provide EAP, Member Assistance Program (MAP), & Physician Assistance Programs (PAP) services specifically to members who are residents of California.
Currently, California regulations consider all EAP plans that offer more than a three-visit clinical assess and refer model as a health plan, forcing EAPs that are not licensed in California to reduce the number of visits they can provide. First Choice Health’s partnership with The Holman Group allows employees and covered family members (members) with First Choice Health’s EAP program who reside in California access to the same mental health benefits as all other members nationwide by leveraging The Holman Group’s Knox Keene license and network.
In order to make this partnership successful, FCH will regularly collect census data from employer groups through a semi-annual attestation, allowing them to gather information on the group’s population count and identify the number of members known to be in the state of California. FCH will then work directly with the group to update their contract to a three-party agreement that includes The Holman Group, which will be at-risk for all California members. It is important to note that this change will not impact a group’s rate. Also, the FCH process for how California members access care will not change: Members will continue to call the main number or go online, and FCH agents will transfer them to The Holman Group who will assume responsibility for the member and assist them in establishing care.