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RESOURCE CENTER AND ARCHIVES

What are preventive care benefits as defined by the new health care law?comment (0)

August 8, 2013


Preventive health services for adults

Most health plans must cover a set of preventive services like shots and screening tests at no cost to you. This includes Marketplace private insurance plans.

Preventive care benefits

Preventive care helps you stay healthy. A doctor isn’t someone to see only when you’re sick. Doctors also provide services that help keep you healthy.

Free preventive services

All Marketplace plans and many other plans must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible. This applies only when these services are delivered by a network provider.

1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked

2. Alcohol Misuse screening and counseling

3. Aspirin use to prevent cardiovascular disease for men and women of certain ages

4. Blood Pressure screening for all adults

5. Cholesterol screening for adults of certain ages or at higher risk

6. Colorectal Cancer screening for adults over 50

7. Depression screening for adults

8. Diabetes (Type 2) screening for adults with high blood pressure

9. Diet counseling for adults at higher risk for chronic disease

10. HIV screening for everyone ages 15 to 65, and other ages at increased risk

11. Immunization vaccines for adults — doses, recommended ages, and recommended populations vary:

  • Hepatitis A
  • Hepatitis B
  • Herpes Zoster
  • Human Papillomavirus
  • Influenza (Flu Shot)
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Tetanus, Diphtheria, Pertussis
  • Varicella

12. Obesity screening and counseling for all adults

13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk

14. Syphilis screening for all adults at higher risk

15. Tobacco Use screening for all adults and cessation interventions for tobacco users

Preventive health services for women

Most health plans must cover additional preventive health services for women, ensuring a comprehensive set of preventive services like breast cancer screenings to meet women’s unique health care needs.

Comprehensive coverage for women’s preventive care

All Marketplace health plans and many other plans must cover the following list of preventive services for women without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible.

This applies only when these services are delivered by an in-network provider.

1. Anemia screening on a routine basis for pregnant women

2. Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer

3. Breast Cancer Mammography screenings every 1 to 2 years for women over 40

4. Breast Cancer Chemoprevention counseling for women at higher risk

5. Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women

6. Cervical Cancer screening for sexually active women

7. Chlamydia Infection screening for younger women and other women at higher risk

8. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”

9. Domestic and interpersonal violence screening and counseling for all women

10. Folic Acid supplements for women who may become pregnant

11. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes

12. Gonorrhea screening for all women at higher risk

13. Hepatitis B screening for pregnant women at their first prenatal visit

14. HIV screening and counseling for sexually active women

15. Human Papillomavirus (HPV) DNA Test every 3 years for women with normal cytology results who are 30 or older

16. Osteoporosis screening for women over age 60 depending on risk factors

17. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk

18. Sexually Transmitted Infections counseling for sexually active women

19. Syphilis screening for all pregnant women or other women at increased risk

20. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users

21. Urinary tract or other infection screening for pregnant women

22. Well-woman doctor visits to get recommended services for women under 65

Preventive health services for children

Most health plans must cover a set of preventive health services for children at no cost when delivered by an in-network provider. This includes Marketplace and Medicaid coverage.

Coverage for children’s preventive health services

All Marketplace health plans and many other plans must cover the following list of preventive services for children without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible.

1. Autism screening for children at 18 and 24 months

2. Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

3. Blood Pressure screening for children at the following ages: 0 to 11 months, 1 to 4 years , 5 to 10 years, 11 to 14 years, 15 to 17 years.

4. Cervical Dysplasia screening for sexually active females

5. Depression screening for adolescents

6. Developmental screening for children under age 3

7. Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

8. Fluoride Chemoprevention supplements for children without fluoride in their water source

9. Gonorrhea preventive medication for the eyes of all newborns

10. Hearing screening for all newborns

11. Height, Weight and Body Mass Index measurements for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

12. Hematocrit or Hemoglobin screening for children

13. Hemoglobinopathies or sickle cell screening for newborns

14. HIV screening for adolescents at higher risk

15. Hypothyroidism screening for newborns

16. Immunization vaccines for children from birth to age 18 — doses, recommended ages and recommended populations vary:

  • Diphtheria, Tetanus, Pertussis
  • Haemophilus influenzae type b
  • Hepatitis A
  • Hepatitis B
  • Human Papillomavirus
  • Inactivated Poliovirus
  • Influenza (Flu Shot)
  • Measles, Mumps, Rubella
  • Meningococcal
  • Pneumococcal
  • Rotavirus
  • Varicella

17. Iron supplements for children ages 6 to 12 months at risk for anemia

18. Lead screening for children at risk of exposure

19. Medical History for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

20. Obesity screening and counseling

21. Oral Health risk assessment for young children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.

22. Phenylketonuria (PKU) screening for this genetic disorder in newborns

23. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk

24. Tuberculin testing for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.

25. Vision screening for all children.

(Source: www.healthcare.gov)

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Catastrophic coverage available

What if you choose not to purchase health care coverage once the Marketplace opens in October and later you have a medical emergency?

If you are under age 30 or you can prove an acceptable financial “hardship,” then you can purchase a plan to help cover expenses for a medical catastrophe, which also covers three primary care visits per year and free, basic preventative care (see story on what preventative care benefits are, this page).

According to www.healthcare.gov, catastrophic health plans “meet all of the requirements applicable to other Qualified Health Plans (QHPs) but … don’t cover any benefits other than three primary care visits per year before the plan’s deductible is met. The premium amount you pay each month for health care is generally lower than for other QHPs, but the out-of-pocket costs for deductibles, copayments and coinsurance are generally higher. To qualify for a catastrophic plan, you must be under 30 years old or get a ‘hardship exemption’ because the Marketplace determined that you’re unable to afford health coverage. 

“If you have a catastrophic plan in the Marketplace, you can’t get lower costs on your monthly premiums or on out-of-pocket costs based on your income.”

(TAB)

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