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Preventive health care services (Covered at 100 percent by your plan) Preventive care: What is it? Preventive care includes services like checkups, screenings and immunizations that can help you stay healthy and may help you avoid or delay health problems. Because many serious conditions such as heart disease, cancer and diabetes are often preventable, it’s important for everyone to get the preventive care they need. Some examples of preventive care services are: Blood pressure, diabetes and cholesterol tests Many cancer screenings such as mammograms and colonoscopies Counseling, screening and vaccines to help ensure healthy pregnancies Regular well-baby and well-child visits Immunizations and vaccinations Some immunizations and vaccinations are also considered preventive care services. Standard immunizations as recommended by the Centers for Disease Control (CDC) include: hepatitis A and B, diphtheria, polio, pneumococcal, measles, mumps, rubella, tetanus and influenza. Understanding what’s covered and what’s not covered If a service is considered preventive care, it will be covered at 100 percent, if provided by an in-network provider. If the preventive care is delivered by an out-of-network provider, you may be responsible for a fee (which could include a copay, coinsurance or deductible). Additionally, if you are receiving preventive services at a doctor’s visit and some nonpreventive care is also provided, you may be required to pay for a portion of the office visit not related to preventive care (see examples below). To get specifics about your plan’s preventive care coverage, call the customer service number on the back of your member ID card. You may want to also ask your doctor if the services you’re receiving at a preventive care visit (such as an annual checkup) are considered standard preventive care. The Affordable Care Act, effective September 23, 2010, requires that services considered preventive care be covered by your health plan at 100 percent, without a copay, coinsurance or deductible. In addition, it expands the types of services that are considered preventive care (which can vary by age, gender, health and family history). To learn more about more about the Affordable Care Act or preventive care and coverage, visit healthcare.gov. Doctor’s visit examples Here are a few examples of doctor’s visits for preventive care in which some of the care does not meet the law’s guidelines and therefore may not be covered at 100 percent: Blue Cross® and Blue Shield® of Minnesota is a nonprofit independent licensee of the Blue Cross and Blue Shield Association Annual checkup plus an ongoing condition: You visit the doctor for your annual checkup. You receive screenings such as diabetes and a lipid profile based on preventive care guidelines. These services are considered preventive care. At the visit, you also talk with your doctor about an ongoing condition such as back pain. If you receive care for this, it not considered preventive care and it may be covered based on your plan (which could include a copay, coinsurance or deductible) Breast cancer screening for women: You visit the doctor for counseling to determine whether your family history suggests that a BRCA test is needed. This consultation is covered as preventive care. The test itself is not considered preventive care and may be covered as a regular medical benefit. Cervical cancer screening for women: A Pap test that screens for human papillomavirus is typically considered regular medical care rather than preventive care. Colonoscopy: While a colonoscopy would generally be considered preventive care, if this screening detects something, it is often considered diagnostic care rather than preventive, as would additional colonoscopies and treatment (and thus may be covered as medical care based on your plan). Flu shot: A flu shot may be covered at 100 percent, but if you visit an out-of-network provider, you may need to pay the provider and then submit a claim for reimbursement. More than one preventive care visit per year: If you visit your ob/gyn for an annual checkup and also visit an internist for routine screenings the same year, only the first office visit will be covered as preventive care (though recommended tests and screenings would be covered at 100 percent). Timing your annual visits: Generally, one preventive care visit per calendar year is covered. The visits can be at any time in the calendar year; they do not need to be 12+ months apart to be covered. Additional resource Healthcare.gov provides detailed information about the Affordable Care Act, required preventive care and coverage.
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