Download Summary Information for Preventive Care Services without Cost

Summary Information for Preventive Care Services without Cost Sharing
Important: This summary lists all preventive care services required to be provided by non-grandfathered plans
under Health Care Reform (applies only to in-network services). If the Plan document language conflicts with
the provisions of this summary, the provisions of this summary will supersede the terms of the Plan.
Category
Summary
Required Preventive Care Services
Service
Applies only to non-grandfathered plans
(Grandfathered status in Plan document)
Covered In-Network Preventive Services
for Adults
Covered In-Network Preventive Services
for Women, Including Pregnant Women
Revised_071113_Documentation Department
Recommendation
Abdominal aortic aneurysm
One-time screening by ultrasonography in men aged 65 to 75 who
have ever smoked
Alcohol misuse
Screening and behavioral counseling interventions in primary care
settings to reduce alcohol misuse by adults
Aspirin to prevent CVD
Use of aspirin for men aged 45 to 79 when potential benefits of
reduction in myocardial infarction outweighs potential harm in
increase in GI hemorrhage and for women aged 55 to 79 when
potential benefits of reduction in ischemic strokes outweighs
potential harm in increase in GI hemorrhage (covered only when
prescribed by a health care provider)
Blood pressure screening
Screening in adults aged 18 and older
Cholesterol screening
Screening for all men aged 35 and older, and for men aged 20 to
35 at risk for CHD; screening for women aged 45 and older at
risk for CHD, and for women aged 20 to 45 at risk for CHD
Colorectal cancer screening
Screening for adults beginning at age 50 and continuing until age
75 using fecal occult blood testing, sigmoidoscopy and
colonoscopy (includes cost of polyp removal)
Depression
Screening for adults when staff-assisted depression care
supports are in place to assure accurate diagnosis, effective
treatment and follow-up
Diabetes (type 2)
Screening for asymptomatic adults with sustained BP (treated or
untreated) greater than 135/80
Diet
Intensive behavioral dietary counseling (by primary care clinicians or
specialists such as dieticians or nutritionists) for adults with
hyperlipidemia and other known risk factors for cardiovascular and
diet-related chronic disease
HIV
Screening for all adults at increased risk (includes HIV test)
Immunization vaccines for adults
Hepatitis A; Hepatitis B; Herpes Zoster; Human
Papillomavirus; Influenza; Measles, Mumps, Rubella;
Meningococcal; Pneumococcal; Tetanus, Diphtheria,
Pertussis; Varicella (doses, recommended ages and
recommended populations vary)
Obesity
Screening for all adults and offer of intensive counseling and
behavioral interventions to promote sustained weight loss for obese
adults
Sexually transmitted infection
(STI)
High-intensity behavioral counseling to prevent STIs for adults at
increased risk
Syphilis
Screening for all adults at increased risk
Tobacco use
Screening for tobacco use for all adults and cessation interventions
for tobacco users (includes prescription-drug coverage)
Alcohol misuse
Screening and behavioral counseling interventions in primary care
settings to reduce alcohol misuse by pregnant women
Anemia
Routine screening for iron-deficiency anemia for asymptomatic
pregnant women
Bacteriuria
Screening for pregnant women at 12-16 weeks’ gestation or at the
first prenatal visit, if later, for asymptomatic bacteriuria with urine
culture
BRCA screening (Breast Cancer
Susceptibility Genes 1 and 2)
Referrals to genetic counseling and evaluation for BCRA testing for
women with family history of increased risk for deleterious mutations
in BCRA 1 and BCRA 2 genes (includes genetic counseling and
BCRA test)
Summary Information for Preventive Care Services without Cost Sharing
Important: This summary lists all preventive care services required to be provided by non-grandfathered plans
under Health Care Reform (applies only to in-network services). If the Plan document language conflicts with
the provisions of this summary, the provisions of this summary will supersede the terms of the Plan.
Category
Summary
Required Preventive Care Services
Applies only to non-grandfathered plans
(Grandfathered status in Plan document)
Service
Recommendation
Covered In-Network Preventive Services
for Women, Including Pregnant Women,
continued
Breast cancer chemoprevention
Counseling for women at high risk for breast cancer and low risk for
adverse effects of chemoprevention, including potential benefits and
harms of chemoprevention
Breast cancer mammography
Screening, with or without clinical breast examination, every 1-2
years for women aged 40 and older
Breastfeeding*
Comprehensive lactation support and counseling by a trained
provider during pregnancy or postpartum, and costs for renting
breastfeeding equipment, for each birth for the duration of
breastfeeding (may include purchase instead of rental)
Cervical cancer
Screening for sexually active women
Chlamydia infection
Screening for all sexually active non-pregnant women aged 24 and
younger, all pregnant women aged 24 and younger and older
pregnant and non-pregnant women at increased risk
Contraception*†
All FDA-approved contraceptive methods, sterilization procedures,
and patient education and counseling, excluding abortifacient
agents, for all women with reproductive capacity as prescribed in
writing by a Physician, Physician’s Assistant, or Nurse Practitioner
within the legally appointed scope of his or her license (These
charges shall be paid as Routine preventive care, as described in
the Plan’s Schedule of Benefits. Covered services include follow up
and management of side effects, counseling for continued
adherence, and device removal. All generic contraceptive drugs and
all brand contraceptive drugs that do not have a generic equivalent
shall be covered at 100% with no co-payment. All brand
contraceptive drugs that do have a generic equivalent shall be
covered at the co-payments stated in the Plan’s Schedule of
Benefits.)
Domestic violence screening*
Annual screening and counseling for interpersonal and domestic
violence (can include brochures or other assessment tools)
Folic acid
Supplements for women planning or capable of pregnancy
containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid (covered only
when prescribed by a health care provider)
Gestational diabetes*
Screening between 24 and 28 weeks’ gestation and at first prenatal
visit for women at high risk for diabetes
Gonorrhea
Screening for all sexually active women, including those who are
pregnant if at increased risk
Hepatitis B
Screening for pregnant women at their first prenatal visit
HPV DNA*
HPV DNA testing for high-risk women with normal cytology results
every 3 years beginning at age 30
Osteoporosis
Routine screening for women aged 65 and older, but beginning at
age 60 for women at increased risk for osteoporotic fractures
Rh incompatibility
Rh (D) blood typing and antibody testing for all pregnant women
during their first visit for pregnancy-related care and repeated Rh (D)
antibody testing for un-sensitized Rh (D)-negative women at 24-28
weeks’ gestation, unless biological father is known to be Rh (D)
negative
STI/HIV*
Annual counseling on STI and annual counseling and screening for
HIV for all sexually active women (includes HIV test)
Syphilis
Screening for all pregnant women
Tobacco use
Screening for tobacco use for all pregnant women and augmented,
pregnancy-tailored counseling for those who smoke (includes
prescription-drug coverage)
Revised_071113_Documentation Department
Summary Information for Preventive Care Services without Cost Sharing
Important: This summary lists all preventive care services required to be provided by non-grandfathered plans
under Health Care Reform (applies only to in-network services). If the Plan document language conflicts with
the provisions of this summary, the provisions of this summary will supersede the terms of the Plan.
Category
Summary
Required Preventive Care Services
Service
Applies only to non-grandfathered plans
(Grandfathered status in Plan document)
Covered In-Network Preventive Services
for Women, Including Pregnant Women,
continued
Well-woman visits*
Recommendation
Annual (or more frequent if necessary) visits to obtain recommended
age-appropriate and developmentally appropriate preventive
services, including preconception and prenatal care
*Non-grandfathered plans are required to provide coverage without cost sharing in the first Plan Year that begins on or after August 1, 2012.
†Group health plans sponsored by certain religious employers are exempt from the requirement to cover contraceptive services. The definition of religious employer for
purposes of the exemption is based solely on Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code, which primarily concerns churches and other houses of
worship. A house of worship is not excluded from the exemption because it provides charitable social services to, or employs, persons of different religious faiths. Eligible
non-exempt, nonprofit religious employers that object to contraceptive coverage on religious grounds are not required to provide contraceptive coverage under the plan. An
eligible organization is one that (1) opposes providing coverage for some or all of any contraceptive services otherwise required to be covered, on account of religious
objections; (2) is organized and operates as a nonprofit entity; (3) holds itself out as a religious organization; and (4) self-certifies that it meets these criteria in accordance
with the provision of the final regulations. An eligible organization must provide a copy of its self-certification to the plan’s third-party administrator by the first plan year
beginning on or after January 1, 2014. The third-party administrator must provide or arrange separate payments for contraceptive services for the women in the health plan
of the organization at no cost to the women or to the organization.
The interim final regulations regarding preventive health services provide that if a recommendation or guideline for a recommended preventive health service does not
specify the frequency, method, treatment, or setting for the provision of that service, the Plan can use reasonable medical management techniques (which generally limit or
exclude benefits based on medical necessity or medical appropriateness using prior authorization requirements, concurrent review, or similar practices) to determine any
coverage limitations under the Plan. Thus, to the extent not specified in a recommendation or guideline, a plan may rely on the relevant evidence base and these
established techniques to determine the frequency, method, treatment, or setting for the provision of a recommended preventive health service. Plans retain the flexibility to
control costs and promote efficient delivery of care by, for example, continuing to charge cost sharing for branded drugs if a generic version is available and is just as
effective and safe.
Covered In-Network Preventive Services
for Children
Revised_071113_Documentation Department
Alcohol and drug use
Assessments for adolescents
Autism
Screening for children at 18 and 24 months
Behavioral assessments
Assessments for children of all ages (0-11 months, 1-4 years, 510 years, 11-14 years, 15-17 years)
Blood pressure screening
Screening for children of all ages (0-11 months, 1-4 years, 5-10
years, 11-14 years, 15-17 years)
Cervical dysplasia
Screening for sexually active females
Congenital hypothyroidism
Screening for newborns
Depression
Screening of adolescents aged 12-18 years for major depressive
disorder when systems are in place to ensure accurate diagnosis,
psychotherapy and follow-up
Developmental screening
Screening for children under age 3 years and surveillance
throughout childhood
Dyslipidemia
Screening for children at higher risk of lipid disorders (1-4 years,
5-10 years, 11-14 years, 15-17 years)
Fluoride Chemoprevention of
dental caries
Supplements for children older than six months of age without
fluoride in their water source
Gonorrhea ocular prophylaxis
Prophylactic ocular topical medication for all newborns
Hearing
Screening for all newborn
Height, weight, body mass
index, head circ., and BP
Measurements for children (0-11 months, 1-4 years, 5-10 years,
11-14 years, 15-17 years)
Hematocrit or Hemoglobin
Screening for children
Hemoglobinopathies (sickle-cell
disease)
Screening for newborns
Heritable Disorders
Screening for newborns
HIV
Screening for adolescents at increased risk (includes HIV test)
Hypothyroidism
Screening for congenital hypothyroidism in newborns
Summary Information for Preventive Care Services without Cost Sharing
Important: This summary lists all preventive care services required to be provided by non-grandfathered plans
under Health Care Reform (applies only to in-network services). If the Plan document language conflicts with
the provisions of this summary, the provisions of this summary will supersede the terms of the Plan.
Category
Summary
Required Preventive Care Services
Service
Applies only to non-grandfathered plans
(Grandfathered status in Plan document)
Covered In-Network Preventive Services
for Children, continued
Covered In-Network Preventive Drugs
Revised_071113_Documentation Department
Recommendation
Immunization vaccines for
children from birth to age 18
Diphtheria, Tetanus, Pertussis ; Haemophilus influenzae type b;
Hepatitis A; Hepatitis B; Human Papillomavirus; Inactivated
Poliovirus; Influenza; Measles, Mumps, Rubella; Meningococcal;
Pneumococcal; Rotavirus; Varicela (doses, recommended ages,
and recommended populations vary)
Iron supplementation
Supplements for children aged 6 to 12 months at risk for anemia
(covered only when prescribed by a health care provider)
Lead
Screening for children at risk of exposure
Medical History
Screening for all children throughout development (0-11 months, 1-4
years, 5-10 years, 11-14 years, 15-17 years)
Obesity
Screening for children aged 6 years and older and offer of/referral to
comprehensive, intensive behavioral interventions to promote
improvement in weight status
Oral health
Risk assessment for young children (0-11 months, 1-4 years, 5-10
years)
Phenylketonuria (PKU)
Screening for newborns
STI
High-intensity behavioral counseling to prevent STIs for all sexually
active adolescents
Tuberculin testing
Testing for children at increased risk of tuberculosis (0-11
months, 1-4 years, 5-10 years, 11-14 years, 15-17 years)
Vision screening
Screening for all children; Screening to detect amblyopia, strabismus
and defects in visual acuity for children younger than 5 years
Aspirin to prevent CVD
Use of aspirin for men aged 45 to 79 when potential benefits of
reduction in myocardial infarction outweighs potential harm in
increase in GI hemorrhage and for women aged 55 to 79 when
potential benefits of reduction in ischemic strokes outweighs
potential harm in increase in GI hemorrhage (covered only when
prescribed by a health care provider)
Contraceptive agents*†
All FDA-approved contraceptive agents, excluding abortifacient
agents, for all women with reproductive capacity as prescribed in
writing by a Physician, Physician’s Assistant, or Nurse Practitioner
within the legally appointed scope of his or her license (All generic
contraceptives and all brand contraceptives that do not have a
generic equivalent shall be covered at 100% with no co-payment. All
brand contraceptives that do have a generic equivalent shall be
covered at the co-payments stated in the Plan’s Schedule of
Benefits.)
Fluoride Chemoprevention of
dental caries
Supplements for children older than six months of age without
fluoride in their water source
Folic acid
Supplements for women planning or capable of pregnancy
containing 0.4 to 0.8 mg (400 to 800 µg) of folic acid (covered only
when prescribed by a health care provider)
Gonorrhea ocular prophylaxis
Prophylactic ocular topical medication for all newborns
Immunization vaccines for adults
Hepatitis A; Hepatitis B; Herpes Zoster; Human
Papillomavirus; Influenza; Measles, Mumps, Rubella;
Meningococcal; Pneumococcal; Tetanus, Diphtheria,
Pertussis; Varicella (doses, recommended ages and
recommended populations vary)
Immunization vaccines for
children from birth to age 18
Diphtheria, Tetanus, Pertussis ; Haemophilus influenzae type b;
Hepatitis A; Hepatitis B; Human Papillomavirus; Inactivated
Poliovirus; Influenza; Measles, Mumps, Rubella; Meningococcal;
Pneumococcal; Rotavirus; Varicela (doses, recommended ages,
and recommended populations vary)
Summary Information for Preventive Care Services without Cost Sharing
Important: This summary lists all preventive care services required to be provided by non-grandfathered plans
under Health Care Reform (applies only to in-network services). If the Plan document language conflicts with
the provisions of this summary, the provisions of this summary will supersede the terms of the Plan.
Category
Summary
Required Preventive Care Services
Applies only to non-grandfathered plans
(Grandfathered status in Plan document)
Covered In-Network Preventive Drugs,
continued
Service
Iron supplementation
Recommendation
Supplements for children aged 6 to 12 months at risk for anemia
(covered only when prescribed by a health care provider)
*Non-grandfathered plans are required to provide coverage without cost sharing in the first Plan Year that begins on or after August 1, 2012.
†Group health plans sponsored by certain religious employers are exempt from the requirement to cover contraceptive services. The definition of religious employer for
purposes of the exemption is based solely on Section 6033(a)(3)(A)(i) or (iii) of the Internal Revenue Code, which primarily concerns churches and other houses of worship.
A house of worship is not excluded from the exemption because it provides charitable social services to, or employs, persons of different religious faiths. Eligible nonexempt, nonprofit religious employers that object to contraceptive coverage on religious grounds are not required to provide contraceptive coverage under the plan. An
eligible organization is one that (1) opposes providing coverage for some or all of any contraceptive services otherwise required to be covered, on account of religious
objections; (2) is organized and operates as a nonprofit entity; (3) holds itself out as a religious organization; and (4) self-certifies that it meets these criteria in accordance
with the provision of the final regulations. An eligible organization must provide a copy of its self-certification to the plan’s third-party administrator by the first plan year
beginning on or after January 1, 2014. The third-party administrator must provide or arrange separate payments for contraceptive services for the women in the health plan
of the organization at no cost to the women or to the organization.
The interim final regulations regarding preventive health services provide that if a recommendation or guideline for a recommended preventive health service does not
specify the frequency, method, treatment, or setting for the provision of that service, the Plan can use reasonable medical management techniques (which generally limit or
exclude benefits based on medical necessity or medical appropriateness using prior authorization requirements, concurrent review, or similar practices) to determine any
coverage limitations under the Plan. Thus, to the extent not specified in a recommendation or guideline, a plan may rely on the relevant evidence base and these established
techniques to determine the frequency, method, treatment, or setting for the provision of a recommended preventive health service. Plans retain the flexibility to control costs
and promote efficient delivery of care by, for example, continuing to charge cost sharing for branded drugs if a generic version is available and is just as effective and safe.
Revised_071113_Documentation Department