Under the Affordable Care Act, the health care reform law passed in 2010, more people now will have health insurance and access to screening test including recommended immunizations with no copays or deductibles. Many adults currently enrolled in health plans already have preventive services coverage that includes vaccines and screening tests. However, some people may continue to have co-payments or other cost-sharing requirements. Because out-of-pocket preventive costs may vary depending on your insurance coverage, please check with your insurance plan to determine your coverage and responsibility.  Talk to your insurance provider to learn more about your preventive benefits.

Your physician may order additional lab tests or procedures that are not considered preventive or covered under your preventive plan.  You will be responsible for the cost of any additional tests that your physician may order.

Our providers at Town and Country Family Physicians do not base their medical care on insurance benefits or reimbursement.  Our goal is to be able to provide the best medical care for you and your family members.

What are my preventive care benefits?

Part 1 Preventive health services for adults

Part 2 Preventive health services for women

Part 3 Preventive health services for children

Part 1

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. Check with your insurance if you have a max benefit for preventive care.  You are responsible for non-covered services due to max benefits.  This is true even if you have not 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:
  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

Part 2

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 visits to get recommended services for women under 65

Part 3

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:
  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.

Patients are always asking, “What is included in my physical exam?”  Preventive services are based on:

  1. Services for male, female, children
  2. Some services are based on age: under 1 year-65 years and over
  3. Some services are based on if you are a new patient vs an established patient

Physical exams consist of the following:  For Informational Purposes Only  (Patients might require less or additional tests not listed under this description), (tests are subject to change without notice)

  1. Examination
  2. Urinalysis
  3. Hemocccult- take home kit/Hemocccult-DRE
  4. EKG
  5. Screening hearing test
  6. Screening eye exam
  7. Immunizations
  8. Laboratory  test- CMP, TSH, CBC, GGT, Iron, Lipids, PSA, Thyroid

Services are not billed as a bulk charge or description to insurance companies.  Services are billed using the appropriate procedure codes/description/fee to all insurance companies.

Your physician may order additional lab tests or procedures that are not considered preventive or covered under your preventive plan.  You will be responsible for the cost of any additional tests that your physician may order.

Our providers at Town and Country Family Physicians do not base their medical care on insurance benefits or reimbursement.  Our goal is to be able to provide the best medical care for you and your family members.

 

 

 

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