Understanding preventive care

Transcription

1 Understanding preventive care We want you to be your healthiest. That s why the preventive services listed here are free for most members. What services are recommended? Know before you go. Preventive services include immunizations, screenings, lab tests and other services that help prevent illness or help find diseases or medical problems before you have symptoms. They re based on national recommendations and the latest medical research Preventive Health Care Guidelines Children... 3 All adults... 6 Women... 9 Pregnant women When are services free? The same service could be preventive (free) or diagnostic (a medical claim). When you have one of the services listed in this guide for preventive purposes by an in-network provider, we ll pay 100% for most plans 1. Your deductible, copayment and coinsurance may apply if you receive the services in this guide for diagnostic reasons (to monitor, diagnose or treat health problems), or if you have preventive services that aren t listed here. If your doctor provides services more frequently than recommended, they re still preventive unless you have symptoms or a medical condition. Preventive care Diagnostic care Reason for service: To prevent health problems. You don t have symptoms. You have a symptom, or you re being checked because of a known health issue. What you ll pay: You won t pay anything. This is a medical claim. Your deductible, copayments and coinsurance may apply. Guidelines change from year to year Our recommendations are based on medical research from nationwide organizations like the American Medical Questions about preventive services? Please call Customer Service at the number on the back of your member ID card. Association, which means they may change based on new research.

2 Examples of preventive and diagnostic services Before you see your doctor or have a test, it s good to know what s preventive and free and what may cost you money. If you have a chronic disease, your doctor may monitor your condition with tests. Because the tests manage your illness, they re not preventive. If you have a preventive screening and a health problem shows up, your doctor may order follow-up tests. In this case, these tests aren t preventive. If your doctor orders tests based on existing symptoms, these tests aren t preventive. If your doctor recommends a test that s not listed in these guidelines, it s not covered as preventive. Service It s preventive when... It s diagnostic when... Colon cancer screening (colonoscopy or sigmoidoscopy) Diabetes screening Osteoporosis screening Your doctor wants to screen for signs of colorectal cancer based on your age or family history. If a polyp is found and removed during your preventive colonoscopy, the colonoscopy and polyp removal are preventive. If the polyp is sent for lab testing, the testing is considered diagnostic. A blood glucose test is used to detect whether you have a problem with your blood sugar, even though you don t have any symptoms. Your doctor recommends a bone density test based on your age or family history. You re having a health problem, like bleeding or irregularity. Or if the polyp you have removed is sent to a lab to be tested for cancer, the lab test is diagnostic. You re diagnosed with diabetes, and your doctor checks your A1c. You re having a health problem, or your doctor wants to determine the success of a treatment. Metabolic panels Never preventive. Always diagnostic. Studies show that a metabolic panel isn t the best test for detecting or preventing illnesses. Prostate exam (PSA) Never preventive. Always diagnostic. National guidelines have changed recently because this test gives many false results. Urinalysis Never preventive. Always diagnostic. New national guidelines say there s no need for this test unless you have symptoms. 2

3 Children s health Care for newborns through to age 18 You can keep track of services by completing the column. More than one child? Visit priorityhealth.com and keyword search preventive for additional copies. Be sure to see the Women s health section on page 9 for more care that s recommended for females. Physical exams (well-child visits) Age Newborn 1 visit 3-5 days after discharge. 0-2 years 1 visit at 2, 4, 6, 9, 12, 15, 18 and 24 months. 3-6 years 1 visit at 30 months and one visit every 12 months for ages years 1 visit every 1-2 years years 1 visit every year. Immunizations Doses, ages and recommendations vary. Vaccine Chicken pox (varicella) 1 dose between months old. Children between 12 months and 12 years can get 1 dose if they have no history of chicken pox. A second dose is given between 4-6 years. 2 doses for children between 7-18 years if no history of the disease and no previous vaccination. Diphtheria, tetanus, whooping cough (pertussis) Flu (influenza) Haemophilus influenza type b Hepatitis A 1 dose of DTaP at 2, 4, 6 and 18 months old. 1 dose of Tdap between 11 and 12 years with a Td booster every 10 years after. Those over 7 years and not previously immunized can get a single dose of TdaP. 2 doses for healthy children between 6 months and 8 years the first time they get it. There should be 4 weeks between the first and second dose. After age 2, children who ve previously had the flu shot can receive 1 dose annually. 1 dose at 2, 4 and 6 months and once between 12 and 18 months old. 2 doses at least 6 months apart between months old. For children not previously immunized, 2 doses can be given at least 6 months apart at your doctor s discretion. 3

4 Vaccine Hepatitis B HPV (human papillomavirus) Polio (inactivated poliovirus) Measles, mumps, rubella (MMR) Meningitis (meningococcal) Pneumonia (pneumococcal) 1 dose to all newborns before leaving the hospital, a second dose between 1-2 months and a third dose between 6-18 months. May begin between 2-18 years old if not immunized as a baby. 3 doses over a 24-week period starting at age 11 for boys and girls. Your doctor may give the vaccine as early as age 9 if the child is at high risk. 1 dose at 2 and 4 months old and between 16 and 18 months (3 doses total). Then, one dose between 4-6 years old. 1 dose between months and a second between 4-6 years. Can be given to older children if no history of vaccination or the disease. 1 dose between years. Doctors may give vaccine as early as age 2 if the child is at high risk. 1 dose at 2, 4 and 6 months and again at 12 to 15 months. Children over age 2 can get a single dose if not previously immunized. Children with an underlying medical condition can receive an additional dose. Children at high risk can be vaccinated after age 7. Rotavirus 1 dose at 2, 4 and 6 months old. Drugs Prescription required. Prescription Iron supplements Oral fluoride supplements Children ages 6-12 months at risk for iron deficiency. Children 6 months and older without fluoride in their water source. Doctor visits and tests Assessments, Alcohol and drug use assessment Anticipatory guidelines as defined by Bright Futures Autism screening Ages during each visit. Counseling to those at risk. At your doctor s discretion for all children throughout their development. At 18 and 24 months. Blood pressure Every year starting at age 3. Congenital hypothyroidism screening Once at birth. 4

5 Assessments, Depression screening and behavioral assessments Developmental screening Dyslipidemia screening Gonorrhea preventive medication Hearing loss screening Height, weight and body mass index Hematocrit or hemoglobin screening Lead screening Medical history Newborn screenings as identified by the federal Health Resources and Services Administration (includes phenylketonuria [PKU] and sickle cell disease) Obesity screening and physical activity and nutrition Oral health risk assessment Sexually transmitted infections (STI) prevention screening and Tobacco-use screening and Tuberculosis (TB) testing Vision screening At your doctor s discretion for children of all ages. At 9 and 18 months old with checkups throughout development. At 2, 4, 6, 8 and 10 years old, then every year through age 18. Routine lab testing is not recommended but may be done for children at high risk. Once at birth. All newborns and at ages 3, 4, 5, 6, 8, 10, 12, 15 and 18 years. Height and weight at each visit up to age 2. After age 2, body mass index. Once at 12 months, once between ages 11 and 18, and once every year for menstruating adolescents. At 12 and 24 months for children at high risk. Risk assessment for lead exposure between 6-12 months old, 24 months and between 2-6 years. All children at each well-child visit. Once at birth. At your doctor s discretion starting at age 6. At 12, 18, 24 and 30 months old and 3 and 6 years old. At your doctor s discretion for all sexually active adolescents. During each visit. Includes cessation interventions for tobacco users and expanded for pregnant tobacco users. At your doctor s discretion for children at high risk. At ages 3, 4, 5, 6, 8, 10, 12, 15 and 18 years. 5

6 Adult health Care for all adults You can keep track of the services you ve had by completing the column. See Women s health on page 9 for more care that s recommended especially for women and pregnant women. Physical exams Age years Once every 2-3 years, annually if desired years Once every 1-3 years. 65 and older One visit every year. Immunizations Doses, ages and recommendations vary. Vaccine Chicken pox (varicella) Flu (influenza) Hepatitis A Hepatitis B HPV (human papillomavirus) Measles, mumps, rubella (MMR) Meningitis (meningococcal) Pneumonia (pneumococcal) Shingles (herpes zoster) Tetanus, diphtheria and whooping cough (pertussis) (Tdap/Td) 2 doses 4 weeks apart for those with no history of vaccination or the disease. 1 dose every year. 2 doses for those at high risk. 3 doses for those at high risk. 3 doses over a 24-week period up to age doses if no history of vaccination or the disease. Can be given after age 40 if at high risk. 1 dose for ages if no history of vaccination. Can be given after age 40 if at high risk. 1 dose for 65 and older. Those at high risk or with a history of asthma or smoking should have 1 dose between ages 19 and 64 with a booster every 5 years. 1 dose for those 60 and older. 1 dose if no history of pertussis vaccine regardless of interval since last tetanus vaccine, followed by Td every 10 years. This vaccine is recommended especially if the patient has contact with children under age 1. 6

7 If your doctor provides services more frequently than recommended, they re still preventive unless you have symptoms or a medical condition. Doctor visits and tests Assessments, Abdominal aortic aneurysm screening Advance care planning Alcohol misuse screening and behavioral Anticipatory guidance for family and intimate partner violence, breast self-exam, menopause, safety, falls and injury prevention Blood pressure screening Cholesterol test (lipoprotein profile) Colon cancer screening Depression screening Diabetes screening (Type 2) Diet Height, weight and body mass index (BMI) Medical history Obesity screening and Once for men ages with a history of smoking. At physical exam. At physical exam. At doctor s discretion. At physical exam. A fasting test (total cholesterol, LDL, HDL and triglyceride) once every 5 years. Beginning at age 50, one of the following screenings: Colonoscopy every 10 years Flexible sigmoidoscopy every 5 years Fecal occult blood test We recommend a colonoscopy because it looks at the entire colon. Those with a family history (first-degree relative) of colorectal cancer or adenomatous polyps should begin screening at age 40 or 10 years before the youngest case in the immediate family with a colonoscopy every five years. During physical exam. For those with a sustained blood pressure greater than 135/80 or with hypertension or hyperlipidemia using a fasting plasma glucose, 2-hour postload plasma or hemoglobin A1c. At your doctor s discretion if you re at high risk for heart and diet-related chronic diseases. During physical exam. During physical exam. Screening and /behavioral interventions at your doctor s discretion. 7

8 Assessments, Sexually transmitted infections (STI) and screening Tobacco-use screening and Tuberculosis (TB) testing At your doctor s discretion for all sexually active adults. At each visit. Includes cessation and interventions (see tobacco cessation products in the Drugs section for tobacco users). Expanded for pregnant women. At your doctor s discretion if you re at high risk of tuberculosis. Drugs Prescription required. Prescription Low-dose aspirin therapy to prevent heart disease Tobacco cessation products For men and women ages and others with risk factors. Consult your doctor before starting. Nicotine replacement or tobacco cessation products are covered for up to three months. Coverage is continued for an additional three months if you have successfully quit smoking (a maximum of six months per calendar year). 8

9 Women s health Care that s recommended only for women You can keep track of the services you ve had by completing the column. See the Adult health section on page 6 for more care that s recommended for all adults. Doctor visits and tests Assessments, Contraceptive and contraception methods 2,3 Counseling and screening for sexually transmitted infections 2 Counseling for breast cancer Counseling related to BRCA screening Domestic violence screening and 2 Human immunedeficiency virus (HIV) and screening 2 HPV (Human papillomavirus testing) 2 Mammogram (breast cancer screening) Osteoporosis screening Pap test (cervical dysplasia/cancer screening) Sexually transmitted infection (STI) prevention Well-woman visits (physical exams) 2 Access to FDA-approved contraceptive methods, sterilization procedures and patient education and. (See page 10 for a list of contraceptives.) Annually for sexually active women. Counseling for women at high risk for breast cancer who may benefit from chemoprevention at your doctor s discretion. Women at high risk. Annually. Annually for sexually active women. Every three years for women starting at age 30, regardless of Pap test results. Once every two years for women ages Begin at age 30 for those at high risk or at your doctor s discretion. Women 65 and older and younger women whose fracture risk is equal to or greater than that of a 65-year-old white female who has no additional risk factors. Start screening at beginning of sexual activity or at age 21, whichever is first. Annual screening up to age 30 (for those with a cervix). For ages 30 and older, screening every 2-3 years. Routine screening for females 65 years and older is not recommended unless identified as high risk. Annual and screening for HIV and sexually transmitted infections for sexually active women. One visit every 1-3 years. 9

10 Contraceptives 2,3 Prescription required. Type Method Benefit level Hormonal Barrier Implantable Oral contraceptives Injectable contraceptives Diaphragms Female condoms Contraceptive sponge IUDs Generic contraceptive methods for women are covered at 100% (free). Your prescription copayment applies for brand name contraceptives. Emergency Ella Next Choice Next Choice One Dose Covered at 100% (free). Permanent Tubal ligation Covered at 100% (free) for outpatient facilities. If received during an inpatient stay, only the services related to the tubal ligation are covered in full. Drugs Prescription required. Prescription Folic acid supplements Women of childbearing age: 0.4 to 0.8 mg at your doctor s discretion. Pregnant women Pregnant women If you re pregnant, plan to become pregnant or recently had a baby, we recommend the preventive care that s listed here. You can keep track of the services you ve had by completing the date received column. Doctor visits and tests Assessments, Bacteriuria screening with urine culture Breastfeeding support, supplies and 2 Gestational diabetes screening 2 Between 12 and 16 weeks gestation or during first prenatal visit if later. Lactation support and to pregnant and postpartum women, including costs for rental of breastfeeding equipment. Women weeks pregnant and those identified as high risk for gestational diabetes. 10

11 Assessments, Hematocrit or hemoglobin screening Hepatitis B screening Iron-deficient anemia screening Rh incompatibility screening During the first prenatal visit. During the first prenatal visit. On a routine basis. On first visit and follow-up testing for women at high risk. Immunizations Doses, ages and recommendations vary. Vaccine Before pregnancy During pregnancy After pregnancy Chicken pox (varicella) Yes, avoid getting pregnant for 4 weeks. No. Yes, immediately postpartum. Hepatitis A Yes, if at risk. Yes, if at risk. Yes, if at risk. Hepatitis B Yes, if at risk. Yes, if at risk. Yes, if at risk. HPV (human papillomavirus) Influenza (LAIV) (Nasal spray) Yes, if between ages 9 and 26. Yes, if less than 50 years of age and healthy. Avoid getting pregnant for 4 weeks. No. Yes, if between ages 9 and 26. No. Yes, if less than 50 years of age and healthy. Avoid getting pregnant for 4 weeks. Influenza (TIV) Yes. Yes. Yes. Measles, mumps, rubella (MMR) Meningococcal (polysaccharide, conjugate) Pneumonia (pneumococcal) Yes, avoid getting pregnant for 4 weeks. No. No. If indicated. If indicated. If indicated. If indicated. If indicated. If indicated. Td Yes (Tdap preferred). If indicated. Yes (Tdap preferred). Tdap (one dose only) Yes. If high risk of pertussis Yes. 11

12 1 If your plan is grandfathered (a plan that hasn t been changed since health reform), we ll pay at your preventive services benefit level, and prescription drugs are covered only if you have a prescription rider. (See your plan documents for details.) You may ask your employer if your plan is grandfathered. Or you may call Customer Service at the number on the back of your ID card. 2 These services do not apply if you re in a grandfathered plan. 3 Group health plans sponsored by certain religious employers are exempt from offering coverage for contraceptive methods, including sterilization procedures. In addition, certain religious organizations may delay the addition of coverage of contraceptive methods and sterilization procedures until their renewal on or after Aug. 1, To determine if your plan includes contraceptive coverage, please contact your employer, or call Customer Service at the number listed on the back of your ID card. The Preventive Health Care Guidelines were developed and approved by Priority Health network doctors. For physician use only: Specific EPSDT requirements may vary from the guidelines. Please refer to the online Provider Manual to review the EPSDT periodicity chart for the mandated health screening program for Medicaid recipients younger than age 21. References: American Academy of Family Physicians American Academy of Pediatrics American Cancer Society American College of Obstetricians and Gynecologists American College of Physicians American Medical Association National Cancer Institute U.S. Preventive Services Task Force, U.S. Public Health Service Go to ahrq.gov/clinic/prevenix.htm for a complete list of evidence-based preventive services and risk factors from USPSTF Priority Health priorityhealth.com PH /12