Preventive Care Services

Transcription

1 Preventive Care Services Accompanies Non-Grandfathered Health Plans What kinds of preventive and wellness services are covered for you and your family at no out-of-pocket cost? As part of the Patient Protection and Affordable Care Act, health insurers must cover some preventive and wellness care for health plan members with non-grandfathered insurance plans. Non-grandfathered plans are plans that began after the Patient Protection and Affordable Care Act was passed in March To help you proactively maintain your health, the preventive services included in this brochure are available to you at no out-of-pocket costs (paid at first dollar) when performed by a network provider. 01MK5220 R12/15

2 DISCLAIMER: The Preventive & Wellness benefits in effect are those required by state or federal law for your policy, at the time the services are rendered. To the extent this Preventive Care Services document conflicts with state or federal requirements, state and federal requirements control. Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company and is an independent licensee of the Blue Cross and Blue Shield Association. HMO Louisiana, Inc. is a subsidiary of Blue Cross and Blue Shield of Louisiana.

3 Preventive Benefits We want to help you protect your health, and that starts with disease prevention and early detection. Preventive screenings are an important way to track your health. If you use a provider in your network, you can receive certain routine preventive services at no extra cost to you. This means the visit is not subject to your annual deductible, copayment or coinsurance. Here s how to prevent health problems and save money using your plan: 1. Get Preventive Care. Follow this guide for how often and at what age you can get these types of care. If you use a provider in your network, you can get the preventive care listed in this guide at no extra cost to you. This means you may not have to pay out of pocket based on your plan, even if you have a deductible or other cost share. 2. See a Primary Care Doctor Regularly. Seeing a primary care doctor regularly to stay ahead of health problems can help you save on health costs. A primary care doctor is a general practice, family medicine or internal medicine doctor for adults, or a pediatrician for children. You can get a physical exam per year at no extra cost with most plans. More Tools for Good Health Blue365 Get discounts for healthy living like sports clothing and shoes, diet programs, fitness trackers, hotels, help for senior care and more. Healthways Fitness Your Way Get discounts on gym memberships through this Blue365 deal. Free Personal Health Assessment A free online health survey that shows any risks you may discuss with your doctor. Lower - or Even $0 - Copays with Quality Blue We work with primary care doctors around the state to help you get the best care possible through a program called Quality Blue Primary Care. If your plan has copayments for primary care office visits, you may be able to pay less or nothing at all when you visit a Quality Blue Primary Care doctor. Look up your doctor s name in our directory at Quality Blue primary care doctors have a blue Q next to their names. Learn more at wellness.bcbsla.com. 1

4 Services for Children (You will pay $0 for these services when received from a network provider.) Examinations or tests Routine wellness physical examination Routine wellness diagnostic tests that a doctor orders (a urinalysis; complete blood count (CBC); serum chemistries; calcium, potassium, cholesterol, and blood sugar levels). Higher tech services such as an MRI, MRA, CT scan, PET scan, nuclear cardiology and endoscopy are not covered under this no-cost benefit but may be covered under other policy benefits. Well baby care All ages As a doctor recommends for developmental milestones Immunizations Immunizations that a doctor recommends All ages Screenings, counseling and supplements Seasonal flu and H1N1 immunizations Depression screening Hepatitis B screening HIV screening and counseling Sexually transmitted infection counseling Skin cancer counseling All ages years Adolescents who are at increased risk Pregnant women Adolescents who are at increased risk Sexually active adolescents years years Syphilis screening Services for females Cervical dysplasia screening for girls years Adolescents who are at increased risk Pregnant women Chlamydia infection screening Contraceptives All Food and Drug Administration (FDA) approved methods, as prescribed by physician. Gonorrhea screening Intimate Partner Violence screening Routine gynecologist or obstetrician visits Permanent Sterilization method Violence and domestic abuse counseling 24 years and younger who are sexually active/older women who are at increased risk for infection If you have reproductive capacity If you are sexually active years As age and developmentally appropriate If you have reproductive capacity As needed 2

5 Services for Children (You will pay $0 for these services when received from a network provider.) Services for pregnant females Other screenings, counseling and supplements Anemia screening Bacteriuria screening Generic over-the-counter (OTC) 81mg aspirin (pharmacy benefit) effective 9/1/15 Gestational diabetes testing and screening Rh incompatibility screening Breast feeding intervention Lactation counseling Lactation supplies for machine use only Manual breast pump Tobacco use and screening Alcohol and drug use assessments Autism screening Behavioral assessments Congenital hypothyroidism screening Developmental screening Dyslipidemia screening Gonorrhea prophylactic ocular medication Hearing screening Height, weight and body mass index measurements Hematocrit or hemoglobin screening Iron supplement Lead screening Obesity screening and counseling Generic folic acid supplements (pharmacy benefit) 0.4mg to 0.8mg/day During pregnancy During weeks of gestation or at first prenatal visit 54 years and younger (for the prevention of preeclampsia) after 12 weeks of gestation Asymptomatic pregnant women after 24 weeks of gestation During weeks if you are at risk or at the first prenatal visit During pregnancy and after birth During each pregnancy and after each birth During the postpartum period During the postpartum period; electric and hospital-grade pumps will process according to your contract benefits During pregnancy years 1-2 years 0-21 years Newborns 0-3 years: Varied intervals From 24 months: Varied intervals Newborns 0-21 years: 1 per benefit period 2-21 years 4 months-21 years: Varied intervals Asymptomatic 6-12 months at risk 0-6 years: 1 per benefit period 6 years and older years planning or capable of pregnancy (continued on next page) 3

6 Services for Children (You will pay $0 for these services when received from a network provider.) Other screenings, counseling and supplements Oral fluoride supplement Oral health assessment Phenylketonuria (PKU) Sickle cell screening for newborns Tobacco use screening and counseling Tuberculosis screening Vision screening 6 months-5 years 6 months-6 years: Varied intervals Newborns Newborns School-aged children and adolescents 0-21 years: 1 per benefit period 0-21 years: 1 per benefit period 4

7 Services for Women (You will pay $0 for these services when received from a network provider.) Examinations or tests Routine wellness physical examination Routine wellness diagnostic tests that a doctor orders (a urinalysis; complete blood count (CBC); serum chemistries; calcium, potassium, cholesterol and blood sugar levels). Higher tech services such as an MRI, MRA, CT scan, PET scan, nuclear cardiology and endoscopy are not covered under this no-cost preventive benefit but may be covered under other policy benefits. Check your benefit plan. Colorectal cancer screening Fecal occult blood test: All ages years: 1 per benefit period For more screenings, you pay Deductible Amounts and Coinsurance percentages shown in the Schedule of Benefits. Flexible sigmoidoscopy: years: 1 every 5 years For more screenings, you pay Deductible Amounts and Coinsurance percentages shown in the Schedule of Benefits. Colonoscopy: years: 1 every 10 years For more screenings, you pay Deductible Amounts and Coinsurance percentages shown in the Schedule of Benefits. Physician prescribed colonoscopy preparation medications: Other Grade A and B screening procedures as most recently recommended by the U.S. Preventive Services Task Force (USPSTF) and the American College of Gastroenterology, in consultation with the American Cancer Society. Services we consider investigational are not covered. Lung cancer screening Low-dose computed tomography: Routine gynecologist or obstetrician visits years of age: limit 2 prescriptions. Selected generic physician prescribed colonoscopy preparation medications when prescribed in conjunction with a wellness colonoscopy screening years Adults years who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years. As age and developmentally appropriate Immunizations Immunizations that a doctor recommends All ages Seasonal flu and H1N1 immunizations All ages (continued on next page) 5

8 Services for Women (You will pay $0 for these services when received from a network provider.) Sexual health and contraception Services for pregnant women Chlamydia infection screening Contraceptives All Food and Drug Administration (FDA) approved methods, as prescribed by physician. Gonorrhea screening Hepatitis B screening HIV screening and counseling Sexually transmitted infection counseling Permanent Sterilization method Syphilis screening Anemia screening Bacteriuria screening Breast feeding intervention Generic over-the-counter (OTC) 81mg aspirin (pharmacy benefit) effective 9/1/15 Gestational diabetes testing and screening Lactation counseling Lactation supplies for machine use only Manual breast pump Rh incompatibility screening Tobacco use screening and counseling 24 years and younger who are sexually active/older women who are at increased risk for infection If you have reproductive capacity If you are sexually active Adults who are at increased risk Pregnant women Adolescents and adults/pregnant women Sexually active adolescents and sexually active women Adults who are at increased risk If you have reproductive capacity Adults who are at increased risk Pregnant women During pregnancy During weeks of gestation or at first prenatal visit During pregnancy and after birth 54 years and younger (for the prevention of preeclampsia) after 12 weeks of gestation Asymptomatic pregnant women after 24 weeks of gestation During each pregnancy and after each birth During the postpartum period During the postpartum period; electric and hospital-grade pumps will process according to your contract benefits. The first prenatal visit and during weeks if you are at risk During pregnancy 6

9 Services for Women (You will pay $0 for these services when received from a network provider.) Services for cancer and other diseases Other screenings, counseling and supplements BRCA genetic testing Screening and counseling Chemoprevention Counseling Film Mammography examination (1 every 12 months with all others processing according to your contract benefits.) Medications for risk reduction of primary breast cancer Osteoporosis screening Human Papillomavirus (HPV) DNA testing Routine pap smear Alcohol misuse screening and counseling Aspirin counseling for the prevention of Cardiovascular Disease Blood pressure screening Cardiovascular Disease counseling Cholesterol screening Depression screening Diet counseling Fall prevention intervention Generic folic acid supplements (pharmacy benefit) 0.4mg to 0.8mg/day Generic/single source brand prescription and overthe-counter (OTC) smoking cessation products. Generic Vitamin D (up to 800 IU) If you have a family history of risk (per guidelines) If you are at high risk for breast cancer years: Baseline (Mammograms for this age group may not be covered under all group policies) years: 1 every 24 months or as a doctor prescribes 50 years and older: 1 every 12 months Asymptomatic women 35 years or older without a prior diagnosis of breast cancer, who are at increased risk for breast cancer 65 years or older Younger women with increased fracture risk 30 years and older: 1 every 3 years as a no-cost preventive benefit, with all other processing according to your contract benefits years: 1 for each benefit period Adults years 18 years and older Adults who are overweight or obese and have additional Cardiovascular Disease risk factors years old if at risk or 45 years and older years and adults Adults with hyperlipidemia and other risk factors 65 years and older years planning or capable of pregnancy 18 years and older: limit 180 days per calendar year 65 years and older Hepatitis C screening High-risk adults or adults born between Intimate Partner Violence screening Obesity screening and counseling Skin cancer counseling Tobacco use screening and counseling years Adults with a body mass index higher than 30 kg/m years Adults Type 2 diabetes screening Asymptomatic adults with blood pressure higher than 135/80 mmhg Violence and domestic abuse counseling Women and adolescent females; annually 7

10 Services for Men (You will pay $0 for these services when received from a network provider.) Examinations or tests Routine wellness physical examination Routine wellness diagnostic tests that a doctor orders (a urinalysis; complete blood count (CBC); serum chemistries; calcium, potassium, cholesterol and blood sugar levels). Higher tech services such as an MRI, MRA, CT scan, PET scan, nuclear cardiology and endoscopy are not covered under this no-cost preventive benefit but may be covered under other policy benefits. Colorectal cancer screening Fecal occult blood test: All ages years: 1 per benefit period For more screenings, you pay Deductible Amounts and Coinsurance percentages shown in the Schedule of Benefits. Flexible sigmoidoscopy: years: 1 every 5 years For more screenings, you pay Deductible Amounts and Coinsurance percentages shown in the Schedule of Benefits. Colonoscopy: Physician prescribed colonoscopy preparation medications: Other Grade A and B screening procedures as most recently recommended by the U.S. Preventive Services Task Force (USPSTF) and the American College of Gastroenterology, in consultation with the American Cancer Society. Services we consider investigational are not covered. Lung cancer screening Low-dose computed tomography: Prostate cancer screening Routine digital rectal exam: Prostate-specific antigen (PSA) test: (not covered on all group policies) years: 1 every 10 years For more screenings, you pay Deductible Amounts and Coinsurance percentages shown in the Schedule of Benefits years of age: limit 2 prescriptions. Selected generic physician prescribed colonoscopy preparation medications when prescribed in conjunction with a wellness colonoscopy screening years Adults years who have a 30 pack-year smoking history and currently smoke or have quit smoking within the past 15 years. 50 year and older: 1 per benefit period Older than 40 years: As recommended by a doctor 50 years and older: 1 per benefit period Older than 40 years: As recommended by a doctor A second visit: Immunizations Immunizations that a doctor recommends All ages Older than 40 years: For follow-up treatment within 60 days after the visit if it is related to a condition that is diagnosed or treated during the visit and recommended by a doctor. Seasonal flu and H1N1 immunizations All ages 8

11 Services for Men (You will pay $0 for these services when received from a network provider.) Screenings, counseling and supplements Abdominal aortic aneurysm screening Alcohol misuse screening and counseling Aspirin counseling for the prevention of Cardiovascular Disease Blood pressure screening Cardiovascular Disease counseling Cholesterol screening Depression screening Diet counseling Fall prevention intervention Generic/single source brand prescription and over-the-counter (OTC) smoking cessation products. Generic Vitamin D (up to 800 IU) Hepatitis B screening years who have ever smoked: 1 per benefit period Adults years 18 years and older Adults who are overweight or obese and have additional Cardiovascular Disease risk factors years old if at risk or 35 years and older years and adults Adults with hyperlipidemia and other risk factors 65 years and older 18 years and older: limit 180 days per calendar year 65 years and older Adults who are at increased risk Hepatitis C screening High-risk adults or adults born between HIV screening and counseling Obesity screening and counseling Sexually transmitted infection counseling Skin cancer counseling Syphilis screening Tobacco use screening and counseling Type 2 diabetes screening Adolescents and adults Adults with a body mass index higher than 30 kg/m2 Sexually active adolescents and sexually active men Adults who are at increased risk years Adults who are at increased risk Adults Asymptomatic adults with blood pressure higher than 135/80 mmhg Preventive or Wellness Care Required by the Patient Protection and Affordable Care Act We are required to cover services recommended by the U.S. Preventive Services Task Force (receiving grades of A or B), the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention, and the Health Resources and Services Administration. This list of covered services changes from time to time. Check the current list of federally recommended Preventive or Wellness Care services at: 9

12 5525 Reitz Avenue Baton Rouge, Louisiana For more information call Blue Cross and Blue Shield of Louisiana is incorporated as Louisiana Health Service & Indemnity Company and is an independent licensee of the Blue Cross and Blue Shield Association