Coverage Policy Manual
Policy #: 2011032
Category: PPACA Preventive
Initiated: September 2010
Last Review: June 2022
  PREVENTIVE SERVICES FOR NON-GRANDFATHERED (PPACA) PLANS: SEXUALLY TRANSMITTED INFECTIONS (STIs), BEHAVIORAL COUNSELING FOR PREVENTION

Description:
The Federal Patient Protection and Preventive Care Act was passed by Congress and signed into law by the President in March 2010.  The preventive services component of the law became effective 23 September 2010. A component of the law was a requirement that all “non-grandfathered” health insurance plans are required to cover those preventive medicine services given an “A” or “B” recommendation by the U.S. Preventive Services Task Force.  
 
Plans are not required to provide coverage for the preventive services if they are delivered by out-of-network providers.
 
Task Force recommendations are graded on a five-point scale (A-E), reflecting the strength of evidence in support of the intervention.  Grade A: There is good evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade B: There is fair evidence to support the recommendation that the condition be specifically considered in a periodic health examination.  Grade C: There is insufficient evidence to recommend for or against the inclusion of the condition in a periodic health examination, but recommendations may be made on other grounds.  Grade D: There is fair evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.  Grade E: There is good evidence to support the recommendation that the condition be excluded from consideration in a periodic health examination.
 
Those preventive medicine services listed as Grade A & B recommendations are covered without cost sharing (i.e., deductible, co-insurance, or co-pay) by Health Plans for appropriate preventive care services provided by an in-network provider.  If the primary purpose for the office visit is for other than Grade A or B USPSTF preventive care services, deductible, co-insurance, or copay may be applied.
 
An additional component of the law was a requirement that all “non-grandfathered” health insurance plans, effective  August 1, 2012, are required to provide coverage without cost sharing consistent with the Health Resources and Services Administration ‘s (HRSA’s) Women's Preventive Services: Required Health Plan Coverage Guidelines. The HRSA-supported health plan coverage guidelines were developed by the Department of Health and Human Services (HHS) commissioned Institute of Medicine (IOM). HHS commissioned an IOM study to review what preventive services are necessary for women’s health and well-being and should be considered in the development of comprehensive guidelines for preventive services for women.  HRSA supports the IOM’s recommendations on preventive services that address health needs specific to women and fill gaps in existing guidelines.
  
 

Policy/
Coverage:
Behavioral counseling to prevent Sexually Transmitted Infections (STIs) is covered for sexually active adolescent members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
Behavioral counseling to prevent Sexually Transmitted Infections (STIs) is covered for adult members (at increased risk for STIs) of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay).
 
Increased risk for Sexually Transmitted Infection is defined as:
    • adults with current STI infections;
    • adults who have multiple current sexual partners;
    • adults from communities with a high population of STIs; OR
    • all sexually active patients in non-monogamous relationships.
 
Six counseling sessions will be allowed per year per member.
 
Counseling to prevent Sexually Transmitted Infections (STIs) is covered annually for all sexually active women members of “non-grandfathered” plans, without cost-sharing (i.e., deductible, co-insurance, or co-pay) (HRSA Recommendation) (EFFECTIVE 8/01/2012).
 
The appropiate ICD-10  codes to report this service are Z71.7, Z71.89, and Z72.51-Z72.53.
 
CPT/HCPCS Codes that may be used to report the counseling include 99401, 99402, 99403, 99404 and G0445. When the primary purpose of the service is the delivery of an evidence-based service in accordance with a US Preventive Services Task Force A or B rating in effect and other preventive services identified in preventive services mandates (legislative or regulatory), the service may be billed with Modifier ‘-33’.  The correct coding as listed for both ICD-10  and CPT or HCPCS codes are also required.
 

Rationale:
The USPSTF recommends high-intensity behavioral counseling to prevent sexually transmitted infections (STIs) for all sexually active adolescents and for adults at increased risk for STIs (Grade B Recommendation).
 
The USPSTF recommendations include the following information:
 
    • Despite advances in the screening, diagnosis, and treatment of STIs, they remain an important cause of morbidity and mortality in the United States.
    • Primary care clinicians and teams can identify adolescents and adults who are at increased risk.
    • There is convincing evidence that high-intensity behavioral counseling interventions targeted to sexually active adolescents and adults at increased risk for STIs reduce the incidence of STIs. These results were found 6 and 12 months after counseling took place.
    • The USPSTF has identified the absence of studies and evidence on behavioral counseling interventions directed towards adults not at increased risk for STIs and non-sexually-active adolescents as a critical gap in the literature.
    • No evidence of significant behavioral or biological harms resulting from behavioral counseling about risk reduction has been found. The USPSTF concluded that the potential harms of counseling are no greater than small.
    • The USPSTF concludes that there is moderate certainty that high-intensity behavioral counseling has a moderate net benefit for sexually active adolescents and for adults who are at increased risk for STIs.
    • The USPSTF concludes that the evidence is currently insufficient to assess the balance of benefits and harms of behavioral counseling for non-sexually active adolescents and for adults who are not at increased risk for STIs.
    • All sexually active adolescents are at increased risk for STIs and should be offered counseling. Adults with current STIs or infections within the past year are at increased risk for future STIs. In addition, adults who have multiple current sexual partners should be considered at increased risk and offered counseling to prevent STIs. Married adolescents may be considered for counseling if they meet the criteria described for adults. Clinicians should also consider the communities they serve. If the practice's population has a high rate of STIs, all sexually active patients in nonmonogamous relationships may be considered to be at increased risk.
    • Among the studies reviewed, successful high-intensity interventions were delivered through multiple sessions, most often in groups, with total durations from 3 to 9 hours. Little evidence suggests that single-session interventions or interventions lasting less than 30 minutes were effective in reducing STIs. Although 2 studies of moderate-intensity interventions did not demonstrate effect, a third study demonstrated that two 20-minute counseling sessions before and after HIV testing resulted in a clinically and statistically significant reduction in STIs. The USPSTF found no studies of abstinence-only counseling programs delivered in the clinical setting.
    • Because of the lower incidence of STIs among adults who are not at increased risk, the potential net benefit of behavioral counseling is likely to be smaller for this population than for those at increased risk. Given the current lack of evidence of effectiveness; the substantial costs in time and money for clinicians, patients, and the health system; and the potential missed opportunity for the provision of higher-priority, evidence-based preventive services, primary care clinicians should consider not routinely offering behavioral counseling to prevent STIs to adults who are not at increased risk for infection. The USPSTF found limited evidence on the counseling of non-sexually-active adolescents, with no effect or harms from brief counseling in 1 small study. Although clinicians may not be able to identify all adolescents who are sexually active, intensive counseling for all adolescents to reach those who are not appropriately identified as at risk is not supported by current evidence and would require significant resources. The effectiveness of less intensive counseling has not been established and the benefits of intensive counseling for adolescents who are identified as at risk may not be generalizable to those who deny sexual activity.
 

CPT/HCPCS:
99401Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 15 minutes
99402Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes
99403Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 45 minutes
99404Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 60 minutes
G0445High intensity behavioral counseling to prevent sexually transmitted infection; face to face, individual, includes: education, skills training and guidance on how to change sexual behavior; performed semi annually, 30 minutes

References: PPACA & HECRA: Public Laws 111-148 & 111-152. The Patient Protection and Affordable Care Act.

Screening for Osteoporosis.(2011) U.S. Preventive Services Task Force. http://www.uspreventiveservicestaskforce.org/uspstf/uspsstds.htm. Last accessed May 2011.


Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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