List of Preventive Care Services Covered at 100% for Non-Grandfathered Group Plans

Transcription

1 The Patient Prtectin and Affrdable Care Act (PPACA) and the Health Care and Educatin Recnciliatin Act f 2010 (HCERA) has designated the services listed belw as preventive benefits and available with n cst-sharing when prvided by an in-netwrk prvider fr members f nngrandfathered grup health plans. These benefits are currently effective unless therwise nted. In additin t the services listed belw, yu may have additinal preventive care benefits cvered under yur health plan that may r may nt be cvered at 100%. Check yur benefit bklet fr details n these additinal preventive care benefits. This infrmatin is intended as a reference tl fr yur cnvenience and is nt a guarantee f payment. This guide is subject t change based n new r revised laws and/r regulatins, additinal guidance and/r BCBSNC medical plicy. Yur prvider has access t current diagnsis and prcedures cdes assciated with these services fr crrect claims submissin. IMPORTANT INFORMATION: Services must be billed with a primary diagnsis f preventive, screening, cunseling, r wellness, if applicable, t qualify and ther restrictins may apply. Services therwise deemed Preventive received inpatient r in an emergency rm r that include additinal prcedures r diagnstic services may be subject t cpayment, deductible and cinsurance. Additinally, these services are subject t certain limitatins depending n medical necessity and ther reasnable medical management techniques. If yu have any questins, please call Custmer Service at the tll-free number listed n yur BCBSNC ID card. Grade A and B Recmmendatins f U.S. Preventive Services Task Frce (USPSTF) currently effective unless therwise nted Screening fr Abdminal Artic Aneurysm (ne time screening fr abdminal artic aneurysm by ultrasngraphy in men ages wh have ever smked) Screening and cunseling t reduce alchl misuse (Screen adults aged 18 years r lder fr alchl misuse and prvide persns engaged in risky r hazardus drinking with brief behaviral cunseling interventins t reduce alchl misuse ) Aspirin t prevent cardivascular disease in men and wmen (recmmends the use f aspirin fr men age when the ptential benefit due t a reductin in mycardial infarctins utweighs the ptential harm due t an increase in gastrintestinal hemrrhage AND fr wmen age when the ptential benefit f a reductin in ischemic strkes utweighs the ptential harm f an increase in gastrintestinal hemrrhage) Screening fr bacteriuria (screening fr asymptmatic bacteriuria with urine culture fr pregnant wmen at weeks' gestatin r at the first prenatal visit, if later) Screening fr high bld pressure (in adults 18 and lder) BRCA risk assessment and genetic cunseling/testing Fr wmen wh have family members with breast, varian, tubal, r peritneal cancer with ne f several screening tls designed t identify a family histry that may be assciated with an increased risk fr ptentially harmful mutatins in breast cancer susceptibility genes (BRCA1 r BRCA2). Wmen with psitive screening results shuld receive genetic cunseling and, if indicated after cunseling, BRCA testing Screening fr breast cancer [mammgraphy] (fr wmen aged 40 r ver every 1-2 yrs, with r withut clinical breast examinatin) Over-the-Cunter (OTC) Aspirin (81 mg) is available nly with a prescriptin. Part f wellness ffice visit. Effective at renewal n r after 1/1/2015 An independent licensee f the Blue Crss and Blue Shield Assciatin. U7181a, 4/15 1

2 CONTINUED USPSTF Grade A and B Recmmendatins Chempreventin f breast cancer (fr clinicians t discuss chempreventin with wmen at high risk fr breast cancer and at lw risk fr adverse effects f chempreventin AND infrm patients f the ptential benefits and harms f chempreventin) Breast cancer preventive medicatins (Clinicians engaged in shared, infrmed decisin making with wmen wh are at increased risk fr breast cancer abut medicatins t reduce their risk. Fr wmen wh are at increased risk fr breast cancer and at lw risk fr adverse medicatin effects, clinicians shuld ffer t prescribe risk reducing medicatins such as tamxifen and ralxifene) Interventins t supprt breast feeding (interventins during pregnancy and after birth t prmte and supprt breastfeeding) Screening fr cervical cancer (in wmen ages 21 t 65 yrs with cytlgy (pap smear) every 3 yrs r, fr wmen ages yrs wh want t lengthen the screening interval, screening with a cmbinatin f cytlgy and human papillmavirus (HPV) testing every 5 yrs) Screening fr chlamydial infectin in nn-pregnant and pregnant wmen (fr all sexually active nn-pregnant and pregnant yung wmen ages 24 and yunger and fr lder, nn-pregnant and pregnant wmen wh are at increased risk) Screening fr chlesterl abnrmalities: *men 35 and lder (fr lipid disrders) *men yunger than 35 (fr ages fr lipid disrders if they are at increased risk fr crnary heart disease) *wmen 20 and lder (fr lipid disrders if they are at increased risk fr crnary heart disease) Chempreventin f dental caries (primary care clinicians t prescribe ral fluride supplementatin at currently recmmended dses t preschl children > 6 m f age whse primary water surce is deficient in fluride. Primary care clinicians apply fluride varnish t the primary teeth f all infants and children starting at the age f primary tth eruptin) Screening fr clrectal cancer (using fecal ccult bld testing annually, sigmidscpy every 5 years, r clnscpy every 10 years, in adults beginning at ages 50-75) Screening fr depressin: *adults (screening fr depressin when staff-assisted depressin care supprts are in place t assure accurate diagnsis, effective treatment, and fllw-up) *adlescents (screening yr lds fr majr depressive disrder when systems are in place t ensure accurate diagnsis, psychtherapy [cgnitive-behaviral r interpersnal], and fllw-up) Preventive services mandate des nt include the chempreventin medicatins. This recmmendatin applies t asymptmatic wmen aged 35 years r lder withut a prir diagnsis f breast cancer, ductal carcinma in situ, r lbular carcinma in situ. Generic risk reducing medicatins are cvered as preventive. Fr members wh have swallwing prblems r may have an intlerance t generic prducts, brand prducts may als be made available by cmpleting this frm and faxing it t the number n the bttm f the dcument. Effective n 10/1/2014 Part f a wellness ffice visit fr children 6 mnths t age 5. Services will nt be cvered beynd the 5th birthday. Fluride varnish applicatin effective at renewal n r after 1/1/2015. (ASO grups cntact yur grup administratr.) Clrectal cancer screening mandate des nt include barium enema r fecal DNA. Part f any prblem r preventive ffice visit. An independent licensee f the Blue Crss and Blue Shield Assciatin. U7181a, 4/15 2

3 CONTINUED USPSTF Grade A and B Recmmendatins Screening fr diabetes (screening fr type 2 diabetes in asymptmatic adults with sustained bld pressure (either treated r untreated) > 135/80) Cunseling fr a healthy diet (intensive behaviral dietary cunseling fr adult patients with hyperlipidemia and ther knwn risk factrs fr cardivascular and diet-related chrnic disease by primary care clinicians r by referral t ther specialists such as nutritinists r dietiticians) Fall Preventin (exercise r physical therapy and vitamin D supplementatin t prevent falls in cmmunity-dwelling adults aged 65 yrs and lder wh are at increased risk fr falls.) Supplementatin with flic acid (fr all wmen planning r capable f pregnancy t take a daily supplement cntaining mg [ mcg] f flic acid) Screening fr Gestatinal diabetes mellitus (fr asymptmatic pregnant wmen after 24 weeks f gestatin) Screening fr gnrrhea fr wmen (all sexually active wmen, including thse wh are pregnant if they are at increased risk fr infectin [if they are yung r have ther individual r ppulatin risk factrs]) Screening fr hearing lss (in all newbrn infants) Prphylactic medicatin fr gnrrhea: *newbrns (cular tpical medicatin fr all newbrns against gncccal phthalmia nenatrum) Screening fr hemglbinpathies (fr sickle cell disease in newbrns) Screening fr Hepatitis B (in pregnant wmen at first prenatal visit and in persns at high risk f infectin) Screening fr Hepatitis C (Screen fr hepatitis C virus (HCV) infectin in persns at high risk fr infectin. The USPSTF als recmmends ne time screening fr HCV infectin in adults brn between 1945 and 1965) Screening fr HIV (n all adlescents ages 15 t 65 years, yunger adlescents and lder adults wh are at increased risk, and all pregnant wmen including thse wh present in labr wh are untested and whse HIV status is unknwn) Screening fr cngenital hypthyridism (in newbrns) Screening fr intimate partner vilence (screen wmen f childbearing age and prvide r refer wmen wh screen psitive t interventin services) Screening fr irn deficiency anemia (in asymptmatic pregnant wmen) Over-the-Cunter (OTC) Vitamin D is available nly with a prescriptin. Over-the-Cunter (OTC) flic acid supplements are available nly with a prescriptin. Effective at renewal n r after 2/1/2015 Service is typically perfrmed in the birth facility r as part f a wellness ffice visit in the event f a hme birth. This medicatin is generally administered t newbrn at birth facility. Service is typically perfrmed in the birth facility r as part f a wellness ffice visit in the event f a hme birth. Screening persns at high risk f infectin effective at renewal n r after 6/1/2015 Effective at renewal n r after 7/1/2014 Service is typically perfrmed in the birth facility r as part f a wellness ffice visit in the event f a hme birth. An independent licensee f the Blue Crss and Blue Shield Assciatin. U7181a, 4/15 3

4 CONTINUED USPSTF Grade A and B Recmmendatins Irn supplementatin in children (rutine irn supplementatin fr asymptmatic children 6-12 m f age wh are at increased risk fr irn deficiency anemia) Lung cancer screening (annual screening fr lung cancer with lw-dse cmputed tmgraphy in adults ages 55 t 80 years wh have a 30 pack-year smking histry and currently smke r have quit within the past 15 years. Screening shuld be discntinued nce a persn has nt smked fr 15 years r develps a health prblem that substantially limits life expectancy r the ability r willingness t have curative lung surgery. Screening fr and Management f Obesity in Adults (screen all adults; clinicians shuld ffer r refer patients with a bdy mass index (BMI) f 30 kg/m2 r higher t intensive, multi-cmpnent behaviral interventins.) Screening and cunseling fr besity: *children (screen children aged 6 yrs and lder fr besity and ffer/refer t cmprehensive, intensive behaviral interventins t prmte imprvement in weight status) Screening fr steprsis (bne density) (screen wmen aged 65 and lder fr steprsis and in yunger wmen whse fracture risk is equal t r greater than that f a 65-year-ld white wman wh has n additinal risk factrs) Screening fr Phenylketnuria (PKU) (in newbrns) Screening fr Rh incmpatibility: *first pregnancy visit (recmmends Rh (D) bld typing and antibdy testing fr all pregnant wmen during their first visit fr pregnancy-related care) *24-28 weeks gestatin (recmmends repeated Rh (D) antibdy testing fr all unsensitized Rh (D)-negative wmen at weeks gestatin unless the bilgical father is knwn t be Rh (D)-negative) Cunseling fr Sexually Transmitted Infectins (recmmends high-intensity behaviral cunseling t prevent STIs fr all active adlescents and fr adults at increased risk fr STIs) Behaviral Cunseling t Prevent Skin Cancer (cunseling children, adlescents, and yung adults aged 10 t 24 yrs wh have fair skin abut minimizing their expsure t ultravilet radiatin t reduce risk fr skin cancer.) Screening fr syphilis: *nn-pregnant persns (screen persns at increased risk fr syphilis infectin) *pregnant wmen (screen all fr syphilis infectin) Over-the-Cunter (OTC) irn supplements are available nly with a prescriptin. Effective at renewal n r after 1/1/2015 Includes nutritin cunseling Includes nutritin cunseling Service is typically perfrmed in the birth facility r as part f a wellness ffice visit in the event f a hme birth. Initial testing is part f the bstetric panel. Cnsidered part f wellness ffice visit. An independent licensee f the Blue Crss and Blue Shield Assciatin. U7181a, 4/15 4

5 CONTINUED USPSTF Grade A and B Recmmendatins Cunseling fr tbacc use (ask all adults abut tbacc use and prvide tbacc cessatin interventins fr thse wh use tbacc prducts AND ask all pregnant wmen abut tbacc use and prvide augmented, pregnancy-tailred cunseling fr thse wh smke) Tbacc use fr children and adlescents (Prvide interventins, including educatin r brief cunseling, t prevent initiatin f tbacc use in schl-aged children and adlescents) FDA-apprved tbacc cessatin prescriptin medicatins and OTC nictine replacement therapy (NRT) cvered at 100%. Limited t a 90 day supply each fr tw cessatin effrts. NRT is available nly with a prescriptin. Effective 1/1/2015. Telephnic cunseling available by calling 844-8NCQUIT. Effective at renewal n r after 9/1/2014. Applicable fr members ver the age f 5. Screening fr visual acuity in children (visin impairment screening fr all children at least nce between the ages f 3 and 5 years t detect the presence f amblypia r its risk factrs) Bright Futures Recmmendatins fr Children currently effective unless therwise nted Sensry Screening - Visin Sensry Screening Hearing (beynd newbrn screening) May be part f well-child visits. May be part f wellness visits. Develpmental Screening Autism Screening Develpmental Surveillance May be part f well-child visits. Psychscial/Behaviral Assessment May be part f well-child visits. Depressin screening frm age 11 Effective at renewal n r after 4/1/2015 Alchl and Drug Use Assessment Hematcrit r Hemglbin Critical cngenital heart defect screening in newbrns Effective at renewal n r after 4/1/2015 Lead Screening (up t 7 yrs) Tuberculin Test Dyslipidemia Screening (Chlesterl) STI/HIV screening between ages Effective at renewal n r after 4/1/2015 Oral Health Anticipatry Guidance May be part f well-child visits. May be part f well-child visits. An independent licensee f the Blue Crss and Blue Shield Assciatin. U7181a, 4/15 5

6 Wmen's Preventive Services currently effective unless therwise nted Well Wman visits Annual, althugh HHS recgnizes that (Well-wman preventive care visit annually fr adult wmen t btain the recmmended several visits may be needed t btain preventive services that are age and develpmentally apprpriate, including all necessary recmmended preventive precnceptin and prenatal care specified as preventive by the USPSTF and nted under services, depending n a wman s the USPSTF sectin abve. This well-wman visit shuld, where apprpriate, include health status, health needs, and ther ther preventive services listed in this set f guidelines. risk factrs. Screening fr gestatinal diabetes In pregnant wmen between 24 and 28 weeks f gestatin and at the first prenatal visit fr pregnant wmen identified t be at high risk fr diabetes. Human papillmavirus (HPV) testing (High-risk human papillmavirus DNA testing in wmen with nrmal cytlgy results.) Cunseling fr sexually transmitted infectins (STIs) fr all sexually active wmen Cunseling and screening fr human immune-deficiency virus (HIV) fr all sexually active wmen Cntraceptin Educatin and cunseling related t cntraceptives and sterilizatin fr wmen with reprductive capacity Surgical sterilizatin (hysterectmies are excluded; hysterectmies are nt perfrmed slely fr sterilizatin) The fllwing cntraceptive methds (devices and assciated prcedures, such as device remval, and pharmaceutical cntraceptives) fr wmen with reprductive capacity. OTC cntraceptives Female cndms, all prducts Spnges, all prducts Spermicides, all prducts Emergency cntraceptin (i.e. mrning after pill, Plan B) Cervical Caps Diaphragms Injectins. Only cvered as preventive fr Medrxyprgesterne Acetate 150 mg. which is the nly drug and dsage used fr cntraceptin. Implantable Rds IUDs Generic ral cntraceptives All generic cntraceptives will be cvered as preventive Brand ral cntraceptives will cntinue t require member cst sharing (e.g. deductible, cpay, and/r cinsurance) Trans-dermal cntraceptives (i.e. cntraceptive patches, ORTHO EVRA ) Vaginal rings (i.e. NuvaRing ) Click here t see a cmplete list f preventive cntraceptives. Screening shuld begin at 30 years f age and shuld ccur n mre frequently than every 3 years Annual Annual. Anesthesia services will pay at 100% nly fr sterilizatin. Sterilizatin cverage applies t all places f service, with the exceptin f the Emergency Rm. Separately billed services are nt cvered under preventive services and are subject t the nrmal benefits based n place f service. Diaphragms, vaginal rings, cntraceptive patches, female cndms, spnges, spermicides, and emergency cntraceptin available nly with a prescriptin. Services fr cntraceptive device remval will be prvided with n cst sharing t apprpriate grups effective July 1, 2013, and frward Diaphragms are available nly thrugh the pharmacy and IUDs are available nly thrugh a prfessinal prvider. An independent licensee f the Blue Crss and Blue Shield Assciatin. U7181a, 4/15 6

7 CONTINUED - Wmen's Preventive Services Breastfeeding supprt, supplies, and cunseling (Cmprehensive lactatin (breastfeeding) supprt and cunseling, by a trained prvider during pregnancy and/r in the pstpartum perid, and csts fr breastfeeding equipment) Certain breast pumps fr pst-partum wmen: + One manual r electric breast pump purchase per delivery is cvered. + Benefit available after member has delivered the baby. + Breast Pumps cme with certain supplies, such as tubing, shields, and bttles. All ther supplies are excluded (i.e. creams, nursing bras, replacement tubing fr breast pump). + Breast pumps must be purchased frm participating DME vendrs. - Nt all participating DME vendrs carry all items; please check with yur lcal participating vendr f chice t see if they carry breast pumps. Edgepark carries breast pumps ( ) r g t the Find A Dctr r Facility page t find a vendr clse t yu. ( + Hspital grade breast pumps are excluded and nt cvered. Screening and cunseling fr interpersnal and dmestic vilence Cunseling cvered at 100% thrugh innetwrk prviders (i.e., OB/GYNs, midwives, facilities) Annual An independent licensee f the Blue Crss and Blue Shield Assciatin. U7181a, 4/15 7

8 Vaccines Recmmended by the Centers fr Disease Cntrl and Preventin (CDC) Diphtheria, Tetanus-Acellular, Pertussis (DTap) Measles, Mumps, Rubella (MMR) Haemphilus Infuenzae Type B (Hib) Hepatitis A Hepatitis B Influenza (Flu) Pneumcccal Meningcccal Human Papillmavirus (HPV) Inactivated Plivirus (IPV) Rtavirus Varicella (Chicken Px) Tetanus-Diphtheria /Tetanus-Diphtheria Acellular Pertussis (Tdap) Herpes Zster (Shingles)* Dses, recmmended ages and recmmended ppulatins vary. All recmmended rutine immunizatins will be allwed with n cst-share. Adult and Child & Adlescent Immunizatin Schedules (fr persns aged 0-6 years, 7-18 years, and catch-up schedule ) Refer t the CDC s psted schedule f immunizatins * The shingles vaccine is cvered in accrdance with the Fd and Drug Administratin (FDA) guidelines. Zstavax is FDA apprved fr peple ver the age f 50. An independent licensee f the Blue Crss and Blue Shield Assciatin. U7181a, 4/15 8