Use Case 44: Measure coverage of preventive care by FFM insurance plans
Use case summary
- Title: Measure coverage of preventive care by FFM insurance plans
- Work item: https://github.com/demand-driven-open-data/ddod-intake/issues/44
- Status: Closed. CMS has confirmed that they do not publish a definitive list preventive services CPT codes. See the Solution section for possible work arounds and alternatives.
- Looking for a standardized, machine readable dataset of preventive services that are covered by private insurance plans for free under ACA. This policy is required and described here: https://www.healthcare.gov/preventive-care-benefits/.
- Value to customer: Data will be used to examine whether patients are being charged copayments or deductibles for claims filed with qualifying services.
- Value to industry/public: Opportunity to save money for patients and in longer term improve health by encouraging use of preventive services.
Current data and limitation
- Data source: https://www.healthcare.gov/preventive-care-benefits/
- How it's used: Can't be used for analytics
- Limitations: Not sufficient to join with claims data
- CPT Code
- Diagnosis code, if applicable
- Any other restrictions, (e.g. age requirement, pregnant women, etc.)
- Date effective
- Update frequency:
- As often as this data is updated by CMS, perhaps on an annual basis.
- Joins between datasets:
- Should be valid CPT and DRG codes
- Lag time: Up to latest plan year
- History: All history since start of FFMs
- Delivery mechanism: Download in any machine readable format (CSV or Excel) is sufficient
As confirmed by CMS, there is no definitive list of preventive service CPTS used by FFM/QHPs.
Short term workaround
- Preventive services CPT codes for Medicare plans could be scraped from the following reference: https://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS_QuickReferenceChart_1.pdf
CPT codes are copyrighted by AMA, so cannot be published by HHS without license. We are looking into whether CMS can publish a machine-readable format of the pdf under the CMS AMA license.
- The CDC Office of the Associate Director for Policy - Prevention has a website listing preventive services billing codes for QHPs: http://www.cdc.gov/prevention/billingcodes.html
This may not be a comprehensive list of all preventive services CPTs used by QHPs.
Billing Codes Your patient’s insurance plan may cover these services 100%--with no co-pays or deductibles for your patient to pay. Many insurers require the clinical provider to code the services in particular ways that often vary by insurer. Diagnosis codes may be required for proper reimbursement for some services. This is not intended to be a comprehensive list, and not all insurers accept all of these coding configurations. For more guidance check with your patient’s insurer and review information from Medicare, CIGNA, UnitedHealthcare, and AAP (Bright Futures and Printable 2012 Version).
CDC has been contacted to see if they have a more user-friendly format of the information contained on the website available (status as of 2015 August 17).