Preventive Care

Common Ground Healthcare Cooperative plans include benefits for two types of preventive care. There is a specific list of preventive care services as defined by the Affordable Care Act that are provided at no cost to you as long as you get them through an in-network doctor. But there are also things that you might consider preventive that are not on this list and could be applied to co-payments, coinsurance and deductibles. The lists are provided below.

 

WE WANT TO  STRENGTHEN YOUR POWER TO AVOID SURPRISE CHARGES.

Preventive care has resulted in surprise bills for our members. Deciding what preventive services to receive is between you and your in-network doctor, but it’s our job help you understand your benefits and some pitfalls that have caused other members to pay more than they expected. The resources to the right are full of helpful tips you should review before receiving preventive care. Feel free to print these off and take them with you to the doctor’s office. It may help you avoid a costly charge for a test that’s not highly recommended by the US Preventive Services Task Force.

 

TIP #1: UNDERSTAND THE DIFFERENCE BETWEEN PREVENTIVE AND DIAGNOSTIC CARE

To avoid surprise charges, it is important to understand that “preventive care” is when you don’t have any history, symptoms or other health concerns about the issue for which they are testing or screening. When you have a history or a health concern, those tests and screenings become “diagnostic” and not preventive because the doctor is trying to diagnose a problem. Diagnostic services are typically covered but they are not covered at no cost to you. They will apply to your benefits (copays, deductibles and coinsurance).

No-Cost-Share Preventive Services Recommended for Adults*

  • Abdominal Aortic Aneurysm One time Screening
    • Men aged 65-75 with a history of smoking
  • Alcohol Misuse Screening & Counseling
  • Anemia Screening – up to age 21
  • Aspirin Use
    • Adults aged 50-59
    • For the primary prevention of cardiovascular disease and colorectal cancer in adults who have a 10% or greater 10-year cardiovascular risk
    • If ordered by physician and a prescription is received from the provider
    • Prescription filled using pharmacy benefit
  • Blood Pressure Screening — This is part of a preventive care wellness exam or office visit
  • Cholesterol Screening (Lipid Disorder) – Ages 20-75
  • Colorectal Cancer Screening- — Ages 45-75 includes screening colonoscopy, sigmoidoscopy, fecal occult blood test (FOBT) and
    Cologuard®
  • Counseling to Promote a Healthy Diet and Physical Activity
    for Cardiovascular Disease Prevention – for adults with cardiovascular risk factors
  • Dyslipidemia Screening – up to age 21
  • Depression Screening
  • Diabetes Type 2 Screening – ages 40-70
  • Diet Counseling and Obesity Screening (Screening and Counseling) for adults with risk factors
  • Hearing testing – up to age 21
  • Hepatitis B Screening – up to age 75
  • Hepatitis C Screening – ages 18-79
  • HIV screening – up to age 65
  • Latent Tuberculosis Infection Testing and Office Visit
  • Lead screening – up to age 21
  • Lung Cancer Screening – ages 55-75
  • Obesity Screening and Counseling, including nutritional therapy – up to age 75
  • Physician Wellness Visit
  • Prostate Cancer Screening — Men ages 40 and older
  • Skin Cancer Prevention Counseling – up to age 24
  • Sexually Transmitted Infection (STI) Prevention Counseling & Screening – includes Chlamydia, Gonorrhea, Syphilis
  • Tobacco Use Screening, Counseling & Interventions
  • Tuberculin Testing (TB skin test) – up to age 21
  • Syphilis screening
  • Vaccinations/Immunizations (includes Immunization administration):
    • Diphtheria, Pertussis and Tetanus – includes:
      • Tetanus and Diphtheria (Td)
      • Tetanus, diphtheria toxoids and acellular Pertussis (Tdap)
      • Diphtheria, tetanus an acellular Pertussis, hepB, and polio inactive (DTaP-HepB-IPV)
      • Diphtheria, tetanus toxoids, acellular pertussis, haemophilus influenza B, and polio inactive (DTap-IPV/Hib)
    • Hepatitis A (HepA, HepA-HepB)
    • Hepatitis B (HepB, HepA-HepB , Hib-HepB)
    • Haemophilus influenza B (Hib, Hib-HepB)
    • Human Papilloma Virus (HPV) – up to age 26, special exceptions may be granted up to age 45 for at risk individuals
    • Influenza (seasonal flu)
    • Measles, Mumps, Rubella (MMR)
    • Meningococcal (MenB, MenB-4C, MenB-FHbp, MPSV4, MCV4, MenACWY-CRM)
    • Pneumococcal (pneumonia)– includes:
      • pneumococcal polysaccharide vaccine, 23-valent (PPSV23)
      • pneumococcal conjugate vaccine, 13-valent (PCV13)
    • Polio (IPV)
    • Rotavirus (RV1, RV5)
    • Varicella/Chicken Pox (VAR)
    • Zoster/Shingles (HZV/ZVL, RZV)
  • Visual Acuity/Screening – up to age 21

If you have questions regarding specific service codes, please contact Member Services at 877.514.2442 for more information about how the services may apply to your benefits.

No-Cost-Share Preventive Services Recommended for Women*

  • Breast Cancer screening & counseling services, including:
    • Breast Cancer Preventive Medication Counseling (Chemoprevention)
    • Breast Cancer Risk Evaluation and Genetic Counseling
    • Breast Cancer Risk Testing (BRCA 1 & 2)
    • Breast Cancer Mammography Screening – ages 40 and older
  • Cervical Cancer Screening (Pap Smear) – ages 21-65
  • Contraception & Sterilization
    • For medications, refer to on our Prescription Drug formulary.
    • Prescriptions filled using pharmacy benefit.
    • Benefit includes but is not limited to IUD insertion/removal, tubal ligation, diaphragm fitting, subdermal implant systems.
  • Domestic & Interpersonal Violence Screening &Counseling – included in the code for a wellness visit.
  • Human Papilloma Virus (HPV) DNA Testing
  • Osteoporosis Screening (bone density) – ages 50 and older
  • Prenatal/Postnatal Screenings & Services:
    • Anemia Screening
    • Bacteriuria Screening
    • Gestational Diabetes (during and after pregnancy)
    • Hepatitis B Screening
    • Rh Incompatibility Screening
    • Rubella Screening
    • Prenatal office visits
    • Folic Acid
      • If ordered by physician and a prescription is received from the provider
      • Prescription filled using pharmacy benefit
      • Pregnant females or of child-bearing age
    • Breastfeeding Support & Counseling, including Lactation Classes
    • Breast Pumps – If ordered by a licensed professional after the birth of a child. Coverage is limited to one standard manual, simple breast pump or one basic single electric pump. A hospital-grade model is not covered.
  • Well woman visits

If you have questions regarding specific service codes, please contact Member Services at 877.514.2442 for more information about how the services may apply to your benefits.

No-Cost-Share Preventive Services Recommended for Children*

  • Physician Wellness Visit includes: Well Child, Well Baby, Psychosocial/Behavioral Assessments
  • Alcohol Misuse Screening & Counseling – ages 11 and older
  • Anemia Screening
  • Autism Screening – ages 1-2
  • Behavioral Assessments – included in the code for a wellness visit.
  • Dental caries (fluoride application) – ages 0-5
  • Depression Screening– ages 12 and older
  • Dyslipidemia Screening —ages 9 – 21
    • Dyslipidemia Risk Assessments for ages 2-16 are included in the code for a wellness visit
  • Gonorrhea preventive Medication
  • Hearing Testing
  • HIV screening – ages 15 and older
  • Childhood Vaccinations/Immunizations (includes Immunization administration):
    • Diphtheria, Pertussis and Tetanus – includes:
      • Diphtheria and tetanus (DT) – ages 0-6
      • Diphtheria, tetanus and acellular Pertussis (DTap) – ages 0-6
      • Diphtheria, tetanus toxoids, acellular pertussis and polio inactive (DTap-IPV) – ages 4-6
      • Diphtheria, tetanus toxoids, acellular pertussis, haemophilus influenza B, and polio inactive (DTap-IPV/Hib)
      • Diptheria, tetanus and acellular Pertussis, hepB, and polio inactive (DTaP-HepB-IPV)
      • Tetanus and Diphtheria (Td)
      • Tetanus, diphtheria toxoids and acellular Pertussis (Tdap)
    • Haemophilus influenza B (Hib, Hib-HepB)
    • Hepatitis A (HepA, HepA-HepB)
    • Hepatitis B (HepB, HepA-HepB , Hib-HepB)
    • Human Papilloma Virus (HPV) – ages 9-26
    • Polio (IPV)
    • Influenza (seasonal flu)
    • Measles, Mumps, Rubella (MMR)
    • Meningococcal (MenB, MenB-4C, MenB-FHbp, MPSV4, MCV4, MenACWY-CRM, Hib-MenCY)
      • Hib-MenCY allowed ages 0-2
      • All others allowed any age
    • Pneumococcal (pneumonia)– includes:
      • pneumococcal polysaccharide vaccine, 23-valent (PPSV23)
      • pneumococcal conjugate vaccine, 13-valent (PCV13)
    • Rotavirus (RV1, RV5)
    • Varicella/Chicken Pox (VAR)
  • Iron Supplements
    • If ordered by physician and a prescription is received from the provider
    • Prescription filled using pharmacy benefit
  • Lead Poisoning Screening
  • Obesity Screening and Counseling, including nutritional therapy
  • Tobacco Use Screening, Counseling & Interventions – ages 11 and up
  • Sexually Transmitted Infection (STI) Prevention Counseling & Screening – includes Chlamydia, Gonorrhea, Syphilis
  • Tuberculin Testing (TB skin test)
  • Skin Cancer Prevention Counseling
  • Vision Screening

Newborn Screening (up to age 1):

  • Hearing/Auditory Screening
  • Hypothyroidism Screening
  • Phenylketonuria (PKU) Screening
  • Sickle Cell Screening
  • Metabolic Screenings

If you have questions regarding specific service codes, please contact Member Services at 877.514.2442 for more information about how the services may apply to your benefits.

Click here to download a full printable list of what may be no-cost-share preventive health services.

Preventive health services are only covered at 100% if received from an in-network provider.

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