Download Minimal Essential Coverage Plan

Minimal Essential Coverage Plan —
with Dependents
Schedule of Benefits
Plan Co-Insurance:
The Plan pays 100% of Reasonable and Appropriate Charges
All Plan co-insurance amounts are stated as a percentage of Reasonable and Appropriate Fees.
“Reasonable and Appropriate” fees shall be limited to covered expenses which are identified as eligible for
payment by the Plan Administrator in accordance with the terms of this Plan.
“Reasonable and Appropriate” amounts are determined and established by the Plan, at the Plan Administrator's
discretion, using normative data such as, but not limited to, the fee(s) which the Provider most frequently charges
the majority of patients for the service or supply, amounts the Provider most often agrees to accept as payment
in full either through direct negotiation or through a preferred provider organization (“PPO”) network, average
wholesale price (AWP) and/or manufacturer’s retail pricing (MRP), the prevailing range of fees charged in the
same “area” by Providers of similar training and experience for the service or supply, rates negotiated with the
Plan, and/or Medicare reimbursement rates. Medicare rates plus 20% are generally considered to be the
Reasonable and Appropriate (and thus Maximum Payable Amount); however, the Plan Administrator may in its
discretion, taking into consideration specific circumstances and negotiated terms, deem a greater amount to
payable.
Benefits
Abdominal aortic aneurysm screening: men
Alcohol and drug use assessment: adolescents
Alcohol misuse: screening and counseling
Anemia screening: pregnant women
Coverage
1 time per year, ages 65-75, previous smoker
1 time per year, ages 11-18
Screening 1 time per year, adults 18 and over, including brief
behavioral interventions up to 5 sessions per year.
At the initial prenatal visit and early in the third trimester
asymptomatic pregnant women
Aspirin to prevent cardiovascular disease: men
As prescribed, ages 45-79, when the potential benefit due to
a reduction in myocardial infarctions outweighs the potential
harm of an increase in gastrointestinal hemorrhage
Aspirin to prevent cardiovascular disease: women
As prescribed, ages 55-79, when the potential benefit of a
reduction in ischemic strokes outweighs the potential harm of
an increase in gastrointestinal hemorrhage
Aspirin to treat preeclampsia in pregnant women
Autism screening: children
As prescribed
At 18 and 24 months
Bacteriuria screening: pregnant women
1 time, pregnant women at 12-16 weeks gestation or at the
first prenatal visit, if later
Behavioral assessments: children
0-11 months: 6 well baby visits; 1-4 years: 7 visits between
ages 1 and 4; 5-18 years: 1 visit per year
Blood pressure screening in adults
1 time per year, 18+ years
MRBP Minimum Essential Coverage Plan—With Dependents
The Boon Group, Inc.
Blood pressure screening in children
0-11 months: 6 well baby visits; 1-4 years: 7 visits between
ages 1 and 4; 5-18 years: 1 visit per year
BRCA risk assessment and genetic counseling/testing
1 time every 5-10 years, beginning at age 18; women whose
family history is associated with an increased risk for
deleterious mutations in BRCA1 or BRCA2; if screening results
are positive receive genetic counseling and if indicated by
counseling, testing.
Breast cancer preventive medication consultation
1 time, women at high risk for breast cancer and at low risk for
adverse effects of chemoprevention
Breast cancer screening/mammography
Breastfeeding counseling
1 time every year, women ages 40 or older
Twice to parent(s) of the child (1 time during pregnancy and 1
time post partum), as well as a breast pump for pregnant and
nursing women.
Cervical cancer screening: Type A
1 time every 3 years, all sexually active women
Cervical cancer screening: Type B
1 time every 5 years, women ages 30-65 who want to
lengthen the screening interval, screening with a combination
of pap smear and human papillomavirus (HPV) testing
1 time per year, women 24 years or younger and for older
women who are at increased risk.
Chlamydial infection screening: pregnant and
nonpregnant women
Cholesterol abnormalities screening: men 35 and older
1 time per year
Cholesterol abnormalities screening: men younger than
35
Cholesterol abnormalities screening: women 45 and
older
Cholesterol abnormalities screening: women younger
than 45
Cholesterol abnormalities: children
1 time per year, ages 20-35 if at increased risk for coronary
heart disease
1 time per year
Colorectal cancer screening
Contraception for women
Dental caries (decay) prevention: preschool children
(through age 5)
Depression screening: adolescents
Depression screening: adults
1 time per year, ages 20-45 if at increased risk for coronary
heart disease
Screening for children at higher risk of lipid disorders, ages 14 years; 5-10 years; 11-14 years; 15-18 years
Ages 50-75
As prescribed, FDA approved methods, sterilization
procedures, and patient education and counseling for all
women not including abortifacient drugs
Oral fluoride as prescribed for preschool children older than 6
months whose primary water source is deficient in fluoride;
fluoride varnish to the child's teeth, 1 time per year beginning
when the first primary tooth appears
1 time per year, ages 11-18
1 time per year, ages 18+
Developmental assessment: children
0-11 months: 6 well baby visits; 1-4 years: 7 visits between
ages 1 and 4; 5-18 years: 1 visit per year
Diabetes screening
1 time per year, asymptomatic adults with sustained blood
pressure (either treated or untreated) greater than
135/80 mm Hg
Domestic and Interpersonal violence screening: women 1 time per year; screening of women of childbearing age for
of childbearing age
intimate partner violence; refer women who screen positive to
intervention services. Applies to women who do not have
signs or symptoms of abuse
Diphtheria, Tetanus and Pertussis-1
1 time age 2 months
Diphtheria, Tetanus and Pertussis-2
1 time age 4 months
MRBP Minimum Essential Coverage Plan—With Dependents
The Boon Group, Inc.
Diphtheria, Tetanus and Pertussis-3
1 time age 6 months
Diphtheria, Tetanus and Pertussis-4
1 time age 15-18 months
Diphtheria, Tetanus and Pertussis-5
Falls prevention in older adults: exercise or physical
therapy
1 time age 4-6 years
1 time per year, community-dwelling adults ages 65 years or
older who are at increased risk for falls
Falls prevention in older adults: Vitamin D
As prescribed, community-dwelling adults ages 65 years or
older who are at increased risk for falls
Folic acid supplementation
Gestational diabetes screening
As purchased, women planning or capable of pregnancy
1 time per pregnancy, women 24-28 weeks pregnant and
those at high risk of developing gestational diabetes
Gonorrhea prophylactic medication: newborns
Gonorrhea screening: women
Healthy diet counseling
Hearing loss screening: newborns
1 time for newborns
1 time per year, women 24 years or younger and for older
women who are at increased risk.
3 times per year, intensive behavioral dietary counseling for
adults with hyperlipidemia and other known risk factors for
cardiovascular and diet-related chronic disease
1 time for newborns
Height, weight, and BMI measurements: children
0-11 months: 6 well baby visits; 1-4 years: 7 visits between
ages 1 and 4; 5-18 years: 1 visit per year
Hematocrit or Hemoglobin screening: children
0-11 months: 6 well baby visits; 1-4 years: 7 visits between
ages 1 and 4; 5-18 years: 1 visit per year
Hemoglobinopathies screening: newborns
Hepatitis B screening: pregnant women
1 time for newborns
1 time at the first prenatal visit
Hepatitis B screening: Nonpregnant adults and
adolescents
Hepatitis C screening: adults
1 time per year for adolescents and adults who are at high risk
for infection
One time screening for adults born 1945-1965; screening for
other adults at high risk for infection.
Hepatitis A-1
1 time, age 12-23 months; adults, those at risk
or traveling
1 time 6 months after Hepatitis A-1; ages 18 months
or older
1 time newborns; adolescents not previously vaccinated;
adults at high risk
1 time, ages 4 weeks-2 months; adolescents not previously
vaccinated; adults at high risk
1 time ages 24 weeks-18 months; adolescents not previously
vaccinated; adults at high risk
Hepatitis A-2
Hepatitis B-1
Hepatitis B-2
Hepatitis B-3
Herpes Zoster
1 time ages 60+ years
H. Influenzae-1
1 time per year, ages 6 weeks-2 months
H. Influenzae-2
1 time per year, ages 10 weeks-6 months
H. Influenzae-3
1 time per year, 14 weeks-6 months
H. Influenzae-4
HIV screening and counseling
1 time per year, 12-15 months
1 time per year for adolescents and adults ages 15-65 and for
younger and older persons at higher risk, including all
pregnant women
HPV-1
1 time per year, ages 9-12 years
HPV-2
1 time per year, ages 9 years, 4 weeks - 12 years,
2 months
MRBP Minimum Essential Coverage Plan—With Dependents
The Boon Group, Inc.
HPV-3
Human Papillomavirus (HPV) DNA Test
Hypothyroidism screening: newborns
1 time per year, ages 9 years, 24 weeks - 12 years,
6 months
1 time every three years for women ages with normal cytology
results who are 30 or older.
1 time for newborns
Polio (IPV-1)
1 time per year, ages 6 weeks-2 months
Polio (IPV-2)
1 time per year, ages 10 weeks-18 months
Polio (IPV-3)
Polio (IPV-4)
1 time per year, ages 14 weeks-18 months
1 time per year, ages 4-6 years
Iron supplementation in children
Influenza, inactivated
LAIV (intranasal influenza)
Lead screening children
Lung cancer screening
As prescribed; ages 6-12 months for children who are at
increased risk for iron deficiency anemia
1 time per year, ages 6 months or older
1 time per year, ages 2-49 years
Ages 6 months-11 months: two times; ages 1-4 years: 5
times; ages 5-6 years: 1 time per year
1 time per year with low dose computed tomography in adults
55 to 80 years who have smoking history of 30 packs per year
and currently smoke or quit within the past 15 years.
Medical history
0-11 months: 6 well baby visits; 1-4 years: 7 visits between
ages 1 and 4; 5-18 years: 1 visit per year
Meningococcal Conjugate vaccine ((MCV4-1)
1 dose ages 11-12 years; also for younger children at
increased risk
1 dose as recommended ages 11 years, 8 weeks-16 years;
also for younger children at increased risk
Meningococcal Conjugate vaccine (MCV4-2)
Measles, Mumps, Rubella vaccine (MMR-1)
1 time age 12-15 months; 1 dose adolescents and adults who
have not had measles, mumps or rubella and have not been
vaccinated; 2 doses adults at higher risk
Measles, Mumps, Rubella vaccine (MMR-2)
1 time age 13 months-6 years
Meningococcal Polysaccharide Vaccine (MPSV4-1)
1 time per year, ages 2+ years; adolescents and adults at
higher risk, as recommended by physician
Meningococcal Polysaccharide Vaccine (MPSV4-1)
1 time per year, ages 7+ years; adolescents and adults at
higher risk, as recommended by physician.
Obesity screening & counseling: adults
Obesity screening & counseling: children
Oral health risk assessment: children
Osteoporosis screening: women
Phenylketonuria screening: newborns
1 time per year for screening; patients with a body mass index
(BMI) of 30 kg/m2 or higher, up to 3 intensive behavioral
counseling sessions per year.
1 time per year, ages 6-18
Ages 6-11 months: 2 times; ages 1-4 years: 5 times;
age 6-10: 1 time per year
1 time per year, women age 65 years and older; 1 per year for
younger women if recommended by a physician.
1 time for newborns
Pneumococcal Conjugate (PCV-1)
1 time age 6 weeks-2 months; adults at high risk
Pneumococcal Conjugate (PCV-2)
1 time age 10 weeks-4 months
Pneumococcal Conjugate (PCV-3)
1 time age 14 weeks-6 months
Pneumococcal Conjugate (PCV-4)
1 time per year, ages 12-15 months
Pneumococcal Polysaccharide (PPSV-1)
1 dose ages 2+ years
Pneumococcal Polysaccharide (PPSV-2)
1 dose, ages 7+ years; another dose at age 65; 1 dose, adults
at high risk
MRBP Minimum Essential Coverage Plan—With Dependents
The Boon Group, Inc.
Prenatal visits
At the intervals recommended; 100% with no copay and no
deductible if billed separately; 40% of a global prenatal and
delivery charge.
Prostate Cancer Screening (Exam and PSA Testing)
Rh incompatibility screening: pregnant women
1 time per year for men age 40 and over
1 time at first prenatal visit and 1 time at 24-28 weeks
gestation, unless the biological father is known to be Rh (D)negative.
Rotavirus-1
1 time per year, ages 6 weeks-2 months
Rotavirus-2
1 time per year, ages 10 weeks-4 months
Rotavirus-3
1 time per year, ages 14 weeks-6 months
Skin cancer behavioral counseling
Sexually Transmitted Infections counseling
Syphilis screening
Tetanus and Diphtheria (td)
Tetanus, Diphtheria and Pertussis for adolescents and
adults (Tdap)
Urinary tract and other infection screening for pregnant
women
Tobacco use counseling on use and cessation
Tobacco use interventions: children and adolescents
Tuberculin Screening: children
1 time per year, ages 10-24 who have fair skin
1 time per year, high intensity behavioral counseling for
sexually active adolescents (ages 11-18) and for adults at
increased risk for STIs
1 time per year, pregnant women and persons at increased
risk for syphilis infection
1 time every 10 years, ages 7+ and after exposure to tetanus
1 time ages 7+ years
3 times, during pregnancy
2 tobacco cessation attempts per year adults and pregnant
women who use tobacco; each consisting of 4 ten minute
counseling sessions (telephone, individual or group) and Food
and Drug Administration (FDA)-approved tobacco cessation
medications (including both prescription and over-the-counter
medications) for a 90-day treatment regimen when prescribed
by a health care provider without prior authorization;
augmented pregnancy counseling tailored to those who
smoke.
Interventions, including education or brief counseling to
prevent initiation of tobacco use in children and adolescents
ages 5-18.
0-11 months: 6 well baby visits; 1-4 years: 7 visits between
ages 1 and 4; 5-18 years: 1 visit per year
Chicken-pox (Varicella-1)
1 time ages 12-15 months; adults and adolescents who have
never had chickenpox and have never been vaccinated
Chicken-pox (Varicella-1)
1 time ages 15 months - 6 years; adults and adolescents who
have never had chickenpox and have never been vaccinated
Vision screening all children
1 time per year ages 3-18
Visual acuity screening: children
1 time every 2 years, ages 3-5
Well-adult routine physical exams
1 time per year for adults ages 18 and older
Well-woman visits
MRBP Minimum Essential Coverage Plan—With Dependents
The Boon Group, Inc.
1 time per year, women only
SmartMEC Plan
Limitations and Exclusions
Some health care services are not covered by the Plan. The following is an example of services that are generally not
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SmartMEC Plan
Limitations and Exclusions (continued)
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