What's new

Effective January 1, 2026, we will expand coverage for preventive breast cancer screening services for our commercial members in alignment with updated federal guidance from the Health Resources and Services Administration (HRSA) and the Women's Preventive Services Initiative (WPSI). These organizations define what can be covered under Affordable Care Act (ACA) preventive care.

What’s changing
Under the new federal guidance, breast cancer screenings will include not only mammograms (currently covered) but also additional imaging and pathology evaluations. These services will be covered as preventive care with no member cost share, regardless of whether the member is enrolled in a health savings account (HSA) or non-HSA plan.

Expanded services include:

• Imaging: MRIs, ultrasounds and contrast mammography
• Pathology: Tissue biopsies and related pathology analysis

This broader coverage applies to members of all risk levels, ensuring that anyone who needs screening—regardless of personal or family history—can access comprehensive services without financial barriers.

Impact on state mandates
The ACA preventive benefit now encompasses requirements already mandated in Oregon and Washington, as well as those going into effect in Idaho on Jan. 1, 2026. While state-specific language may still appear in policy documents, the benefits themselves will be administered under ACA preventive guidelines, which are broader and more inclusive.

Clarification on cancer diagnoses
A key distinction for 2026 is how screenings are handled for members with an active cancer diagnosis:

• These screenings are not considered preventive under ACA or Internal Revenue Services (IRS) guidelines
• Therefore, standard radiology cost shares will apply, even for non-HSA products

For HSA products:

• Deductibles will be waived only for members without an active cancer diagnosis
• Members with an active cancer diagnosis will have deductible applied, consistent with IRS Notice 2024-75

Preventive care flyer updates

Our preventive flyers have been updated to reflect the expanded breast cancer screening coverage.

10/27/2025

Arkansas Blue Cross and Blue Shield announced a new brand within its family of affiliates: Skai Blue Cross Blue Shield. Skai Blue is a new third-party administrator (TPA) that will more broadly support the company's national business and clients.

The brand name Skai — a Scandinavian word meaning "atmosphere as seen from Earth"— is designed to evoke a sense of clarity and limitless potential. The distinctive spelling was carefully selected to represent the unique capabilities and services provided through (or with) the brand.

Arkansas Blue Cross' national accounts are currently serviced by BlueAdvantage Administrators of Arkansas (BAAA), Arkansas's largest third-party administrator (TPA) and an operating division of Arkansas Blue Cross. Skai Blue will serve as a new TPA, administering health plan benefits for the company's self-funded national accounts and future national business.

To learn more, visit SkaiBlueCross.com.

10/27/2025

We've updated our HIV Pre-Exposure Prophylaxis (PrEP) coverage to ensure all appropriate services are covered with no member copay or coinsurance in alignment with the Affordable Care Act FAQ (Part 68) and U.S. Preventive Services Task Force regulatory guidance.

Claims to be reprocessed

• We will begin reprocessing claims by early November 2025 for qualified services received from August 1, 2024, through October 9, 2025. Members will receive an updated Explanation of Benefits.
• Providers who performed eligible services during this time will need to refund any applicable cost share payments to their patients.
  • If a member used HSA funds to pay their provider, the member may need to deposit those funds back into their HSA to avoid tax implications. (Members can consult their tax advisor or HSA administrator for guidance.)

What's covered on or after August 1, 2024

• PrEP medications and monitoring services
• Required laboratory testing and screenings, such as kidney function and sexually transmitted diseases
• Office visits for PrEP consultation and follow-up

Important coding requirements
Best practice: Use Z29.81 (Encounter for HIV pre-exposure prophylaxis) when possible, as this is the most specific code for PrEP services.

To ensure proper claim processing and prevent appeals, please note these diagnosis code coupling requirements.

For claims using codes non-specific to PrEP therapy, additional diagnosis codes are required:

• Z79.899 (Other long term current drug therapy)
  • For professional claims, Z79.899 must be in the primary position. For facility claims, Z79.899 can be in any position.
  • The claim must include one or more of these additional codes: Z29.81, Z20.6, Z72.51, Z72.52, Z72.53.
• Z51.81 (Encounter for therapeutic drug level monitoring) -
  • For professional claims, Z51.81 must be in the primary position. For facility claims, Z51.81 can be in any position.
  • The claim must include one or more of these additional codes: Z29.81, Z20.6, Z72.51, Z72.52, Z72.53.

10/21/2025

Provider search on our authenticated member website and Regence app now features provider performance ratings to help members identify high-performing, high-value, in-network providers. Ratings are based on objective, third-party data and analytics, as well as health plan claims data, and evaluate physicians based on a comprehensive evaluation of evidence-based medicine (quality and appropriateness of care) and cost efficiency.

• For members, higher-rated providers appear at the top of search results, although results can still be sorted according to their preference, such as by distance or name.
• For physicians, these ratings showcase your commitment to quality and value, helping connect you to patients who will benefit most from your expertise.

Provider Performance Scorecards
Physicians can access personalized Provider Performance Scorecards that include:

• Their overall rating level
• Detailed breakdowns of performance in each evaluation category
• Comparison to peer benchmarks
• Specific metrics that influence ratings
• Suggestions for improvement in performance

To view your scorecard, sign into Availity Essentials: Payer Spaces>Provider Reports>Credentialing & Maintenance Reports>Provider Performance Report.

Learn more
Sign into Availity Essentials: Regence Payer Spaces>Resources>Provider Performance Ratings to view:

• A comprehensive guide to provider performance ratings
• An overview of Provider Performance Scorecards
• Answers to frequently asked questions
• Detailed information about the reconsideration process
• Performance measure guides

Read more about provider performance ratings in the May special edition and June issues of our newsletter.

6/30/2025