Your NC State Health Plan Now Covers Preventive Care, Too

durham weight lossOne of the biggest health insurance providers in North Carolina is Blue Cross/Blue Shield of North Carolina (BCBSNC), and three of their core insurance products cover thousands of state workers and teachers in the North Carolina State Health Plan.

Not all State Plans are Equal

If you are on one of Blue Cross/Blue Shield’s health plans for teachers and state employees, open enrollment runs through October 31, 2014. During open enrollment, you have the opportunity to select a health plan that will give you access to benefits mandated by the Affordable Care Act (ACA), also known as Obamacare. However, not all State Health Plans are created equally when it comes to covering preventive care like obesity prevention, health coaching, and nutritionist services.

Prevention is Free

In the past, preventive services like obesity screening, nutritional counseling, and health coaching were excluded from many insurance plans. However, new ACA-compliant plans are required to cover preventive care 100%, with a $0 copay and $0 deductible. As more and more plans comply with the ACA, it is becoming easier for patients to get help controlling their weight, developing healthy eating habits, and staying physically active.

How the ACA Helps

The Affordable Care Act is a raft of legislation that is intended to get all Americans enrolled in health insurance plans. Additionally, ACA addressed gaps in health care insurance coverage so that people can get access to critical health services, like screening for high blood pressure, routine check-ups, and behavior intervention and counseling for obesity.

Here are a few of the preventive services that ACA requires health plans to provide 100% free of charge:

  • Obesity screening and counseling for children and adults
  • Blood pressure screening
  • Type 2 Diabetes screening for adults with high blood pressure
  • Cholesterol screening for increased-risk adults
  • Gestational diabetes screening for pregnant women

The Obesity Epidemic

In 2012, the U.S. Preventive Services Task Force recommended that all obese Americans be given access to intensive counseling and behavioral intervention to reduce body weight, prevent Type 2 Diabetes, and develop healthy living habits. The Task Force noted that weight management counseling for obesity is most effective when it is intensive and ongoing; with patients receiving behavioral intervention and weight loss support over 12 to 26 sessions.

1 in 3 American adults are obese, and the long-term negative consequences and costs of excess body weight are astronomical. In June 2013, the American Medical Association formally recognized obesity as a disease, and noted that treating and preventing obesity require a full range of medical interventions. Being overweight or obese is a risk factor for many life-threatening or fatal health conditions, such as hypertension, Type 2 Diabetes, gestational diabetes during pregnancy, cardiovascular disease, heart attacks, stroke, and other grave health problems.

What You Need to Know

If you are a member of the North Carolina State Health Plan, what is covered and what is excluded by your insurer can be confusing, especially because not all of BCBSNC’s plans for state workers are ACA-compliant.

Here is a run-down of what you need to know about ACA’s preventive coverage mandates and the plans offered by Blue Cross/Blue Shield for teachers and state employees.

Traditional 70/30 Plan

The Traditional 70/30 Plan is Blue Cross/Blue Shield’s most basic health insurance plan. For major medical care like hospital stays, this plan covers 70% of expenses and the enrollee is responsible for 30% of costs after the $933 individual deductible ($2,799 for families) is reached. This plan is considered “grandfathered” by Blue Cross/Blue Shield, and so it does not provide enrollees with completely free preventive services that are required by ACA. 70/30 enrollees with diabetes can have 6 nutritional counseling visits per year with an in-network provider, and those sessions are 100% covered. For people with other nutrition-related health diagnoses, the 70/30 plan covers 4 nutritional counseling visits per year, covered at 100% in-network. If you wish to use the Traditional 70/30 Plan for preventive services or obesity management, the visit might be covered, but each time you see a provider, you will be responsible for the copay ($35 for primary care physicians, $81 for specialists), and members are limited to 4 visits per year for the evaluation and treatment of obesity.

Enhanced 80/20 Plan

The Enhanced 80/20 Plan covers 80% of major medical expenses once the enrollee pays enough to reach the plan’s deductible of $700 for individuals or $2,100 for families. This plan is considered “grandfathered” by BCBSNC and so it does not comply with all elements of the ACA, however most preventive services are covered. Obesity screening and treatment services are 100% covered by the Enhanced 80/20 Plan without a copay at in-network doctor’s offices and outpatient clinics, but enrollees are limited to 4 office visits related to treating or diagnosing obesity per year. Nutritional counseling is covered 100%, as long as the provider is in the BCBS network and the patient has a medical situation that indicates that preventive or wellness services are warranted. Diabetes treatment and management services are also covered. Unlike the 70/30 plan, the Enhanced 80/20 plan allows some enrollees to obtain nutritional counseling in order to achieve health goals like maintaining a healthy weight.

Consumer-Driven Health Plan (CDHP)

The Consumer-Driven Health Plan is Blue Cross/Blue Shield’s newest offering in the NC State Health Plan. This plan is compliant with the preventive services mandate of the ACA and it is not considered “grandfathered” by BCBSNC. Therefore, all preventive services for nutrition, diet and weight management, diabetes prevention and care, and other critical wellness services are all 100% free with no copay due at the time of your visit with a medical provider. The trick here is to make sure that services are coded as “preventive” and not “diagnostic.” If a preventive service for obesity, for instance, is coded as “diagnostic,” the deductible and coinsurance will apply and the enrollee is required to bear some cost for services. The CHDP plan covers 4 office visits per year for the evaluation and treatment of obesity.

Where to Get Preventive Care

If you are insured by one of Blue Cross/Blue Shield’s health plans for teachers and state employees, you can get help preventing and treating many serious health conditions at LifeStyle Medical Center in Durham. The interdisciplinary team at LifeStyle Medical Center works with patients to create personalized, evidence-based treatment plans to help you combat high blood pressure, diabetes, obesity or excess body weight, high cholesterol, gestational diabetes, and other health issues. LifeStyle Medical Center employs strategies like diet and nutritional counseling, exercise planning, and thorough medical evaluation to help you eat right, get the physical exercise you need to get and stay healthy, and manage your wellness. Contact LifeStyle Medical Center today and learn how our expert team uses nutritional counseling, lifestyle modification, and clinical outcomes to develop realistic and individualized health goals for our patients.

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