Common use of Preventive Health Care Services Clause in Contracts

Preventive Health Care Services. In addition to any other preventive benefits described in the group contract or certificate, the Health Plan shall cover the following preventive Services and shall not impose any cost-sharing requirements, such as Deductibles, Copayment amounts, or Coinsurance amounts to any Member receiving any of the following benefits for Services from Plan Providers: 1. Evidenced-based items or Services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force, except that the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention of breast cancer shall be considered the most current other than those issued in or around November 2009. (To see an updated list of the “A” or “B” rated USPSTF Services, visit: xxx.xxxxxxxxxxxxXxxxxxxxxxxxxxxxx.xxx); 2. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved. (Visit the Advisory Committee on Immunization Practices at: xxxx://xxx.xxx.xxx/vaccines/acip/index.html); 3. With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. (Visit HRSA at: xxxx://xxxx.xxxx.xxx); and 4. With respect to women, such additional preventive care and screenings, not described in paragraph 1 above, as provided for in comprehensive guidelines supported by the Health Resources and Services Administration (Visit HRSA at xxxx://xxxx.xxxx.xxx), except for those Services excluded in Exclusions. The Health Plan shall update new recommendations to the preventive benefits listed above at the schedule established by the Secretary of Health and Human Services. We cover medically appropriate preventive health Care Services based on your age, sex or other factors, as determined by your Primary Care Plan Physician in accordance with national preventive health care standards. These Services include the exam, screening tests and interpretation for: 1. Preventive care exams, including: a. Routine physical examinations and health screening tests appropriate to your age and sex; b. Well-woman examinations, including visits to obtain necessary preventive care, and preconception care and prenatal care; and c. Well childcare examinations; 2. Routine and necessary immunizations (travel immunizations are not preventive and are covered under Outpatient Care) for children and adults in accordance with Plan guidelines. Childhood immunizations include diphtheria, pertussis, tetanus, polio, hepatitis B, measles, mumps, rubella and other immunizations as may be prescribed by the Commissioner of Health; 3. An annual pap smear, including coverage for any FDA-approved gynecologic cytology screening technology; 4. Low dose screening mammograms, including 3-D mammograms to determine the presence of breast disease is covered as follows: a. One mammogram for persons age 35 through 39; b. One mammogram biennially for persons age 40 through 49; and c. One mammogram annually for person 50 or older; 5. Adjuvant breast cancer screening, including magnetic resonance imaging (MRI), ultrasound, screening, or molecular breast imaging of the breast, if: a. A mammogram demonstrates a Class C or Class D breast density classification; or b. A woman is believed to be at an increased risk for cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications of an increased risk for cancer as determined by a woman’s physician or advanced practice registered nurse. 6. Bone mass measurement to determine risk for osteoporosis; 7. Prostate Cancer screening including diagnostic examinations, digital rectal examinations, and prostate antigen (PSA) tests provided to men who are age 40 or older; 8. Colorectal cancer screening in accordance with screening guidelines issued by the American Cancer Society including fecal occult blood tests, flexible sigmoidoscopy, and screening colonoscopy; 9. Cholesterol test (lipid profile); 10. Diabetes screening (fasting blood glucose test); 11. Sexually Transmitted Disease (STD) screening and counseling (including chlamydia, gonorrhea, syphilis and Human Papillomavirus (HPV)), subject to the following: a. Annual chlamydia screening is covered for: i. Women under age 20 if they are sexually active; and ii. Women age 20 or older, and men of any age, who have multiple risk factors, which include: a) Prior history of sexually transmitted diseases; b) New or multiple sex partners; c) Inconsistent use of barrier contraceptives; or d) Cervical ectopy; b. Human Papillomavirus (HPV) testing as recommended for cervical cytology screening by the American College of Obstetricians and Gynecologists; 12. HIV screening and counseling; 13. TB tests; 14. Newborn hearing screenings that include follow up audiological examinations, as recommended by a physician or audiologist, and performed by a licensed audiologist to confirm the existence or absence of hearing loss when ordered by a Plan Provider; 15. Associated preventive care radiological and lab tests not listed above; 16. BRCA counseling and genetic testing is covered at no Cost Share. Any follow up Medically Necessary treatment is covered at the applicable Cost Share based upon type and place of Service; and 17. CT scan of the Thorax when ordered as a preventive for smokers age 55 to 80 years of age. Pursuant to IRS Notice 2019-45, coverage is provided for expanded preventive care Services for labs and screenings without any Cost Sharing requirements such as Copayments, Coinsurance amounts and Deductibles: 1. Retinopathy screening for diabetics 2. HbA1C for diabetics 3. Low density Lipoprotein lab test for people with heart disease 4. INR lab test for liver failure and bleeding disorders Note: Refer to Diabetes Treatment, Equipment and Supplies for coverage of glucose monitoring equipment. Note: Refer to Durable Medical Equipment for coverage of peak flow meters. Note: Refer to Outpatient Care for coverage of non-preventive diagnostic tests and other covered Services. See the benefit-specific limitations immediately below for additional information.

Preventive Health Care Services. In addition to any other preventive benefits described in the group contract or certificate, the Health Plan shall cover the following preventive Services and shall not impose any cost-sharing requirements, such as Deductibles, Copayment amounts, amounts or Coinsurance amounts to any Member receiving any of the following benefits for Services from Plan Providers: 1. Evidenced-based items or Services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force, except that the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention of breast cancer shall be considered the most current other than those issued in or around November 2009. (To see an updated list of the “A” or “B” rated USPSTF Services, visit: xxx.xxxxxxxxxxxxXxxxxxxxxxxxxxxxx.xxx); 2. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved. (Visit the Advisory Committee on Immunization Practices at: xxxx://xxx.xxx.xxx/vaccines/acip/index.html); 3. With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. (Visit HRSA at: xxxx://xxxx.xxxx.xxx); and 4. With respect to women, such additional preventive care and screenings, not described in paragraph 1 above, as provided for in comprehensive guidelines supported by the Health Resources and Services Administration (Visit HRSA at xxxx://xxxx.xxxx.xxx), except for those Services excluded in Exclusions. The Health Plan shall update new recommendations to the preventive benefits listed above at the schedule established by the Secretary of Health and Human Services. We cover medically appropriate preventive health Care Services based on your age, sex or other factors, as determined by your Primary Care Plan Physician in accordance with national preventive health care standards. These Services include the exam, screening tests and interpretation for: 1. Preventive care exams, including: a. Routine physical examinations and health screening tests appropriate to your age and sex; b. Well-woman examinations, including visits to obtain necessary preventive care, and preconception care and prenatal care; and c. Well childcare child care examinations; 2. Routine and necessary immunizations (travel immunizations are not preventive and are covered under Outpatient Care) for children and adults in accordance with Plan guidelines. Childhood immunizations include diphtheria, pertussis, tetanus, polio, hepatitis B, measles, mumps, rubella and other immunizations as may be prescribed by the Commissioner of Health; 3. An annual pap smear, including coverage for any FDA-approved gynecologic cytology screening technology; 4. Low dose screening mammograms, including 3-D mammograms to determine the presence of breast disease is covered as follows: a. One mammogram for persons age 35 through 39; b. One mammogram biennially for persons age 40 through 49; and c. One mammogram annually for person 50 or older; 5. Adjuvant breast cancer screening, including magnetic resonance imaging (MRI), ultrasound, screening, or molecular breast imaging of the breast, if: a. A mammogram demonstrates a Class C or Class D breast density classification; or b. A woman is believed to be at an increased risk for cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications of an increased risk for cancer as determined by a woman’s physician or advanced practice registered nurse. 6. Bone mass measurement to determine risk for osteoporosis; 7. Prostate Cancer screening including diagnostic examinations, digital rectal examinations, and prostate antigen (PSA) tests provided to men who are age 40 or older; 8. Colorectal cancer screening in accordance with screening guidelines issued by the American Cancer Society including fecal occult blood tests, flexible sigmoidoscopy, and screening colonoscopy; 9. Cholesterol test (lipid profile); 10. Diabetes screening (fasting blood glucose test); 11. Sexually Transmitted Disease (STD) screening and counseling (including chlamydia, gonorrhea, syphilis and Human Papillomavirus (HPV)), subject to the following: a. Annual chlamydia screening is covered for: i. Women under age 20 if they are sexually active; and ii. Women age 20 or older, and men of any age, who have multiple risk factors, which include: a) Prior history of sexually transmitted diseases; b) New or multiple sex partners; c) Inconsistent use of barrier contraceptives; or d) Cervical ectopy; b. Human Papillomavirus (HPV) testing as recommended for cervical cytology screening by the American College of Obstetricians and Gynecologists; 12. HIV screening and counseling; 13. TB tests; 14. Newborn hearing screenings that include follow up audiological examinations, as recommended by a physician or audiologist, and performed by a licensed audiologist to confirm the existence or absence of hearing loss when ordered by a Plan Provider; 15. Associated preventive care radiological and lab tests not listed above; 16. BRCA counseling and genetic testing is covered at no Cost Share. Any follow up Medically Necessary treatment is covered at the applicable Cost Share based upon type and place of Service; and 17. CT scan of the Thorax when ordered as a preventive for smokers age 55 to 80 years of age. Pursuant to IRS Notice 2019-45, coverage is provided for expanded preventive care Services for labs and screenings without any Cost Sharing requirements such as Copayments, Coinsurance amounts and Deductibles: 1. Retinopathy screening for diabetics 2. HbA1C for diabetics 3. Low density Lipoprotein lab test for people with heart disease 4. INR lab test for liver failure and bleeding disorders Note: Refer to Diabetes Treatment, Equipment and Supplies for coverage of glucose monitoring equipment. Note: Refer to Durable Medical Equipment for coverage of peak flow meters. Note: Refer to Outpatient Care for coverage of non-preventive diagnostic tests and other covered Services. See the benefit-specific limitations immediately below for additional information.;

Preventive Health Care Services. In addition to any other preventive benefits described in the group contract or certificate, the Health Plan shall cover the following preventive Services and shall not impose any cost-sharing requirements, such as Deductibles, Copayment amounts, amounts or Coinsurance amounts to any Member receiving any of the following benefits for Services from Plan Providers: 1. Evidenced-based items or Services that have in effect a rating of "A" or "B" in the current recommendations of the United States Preventive Services Task Force, except that the current recommendations of the United States Preventive Service Task Force regarding breast cancer screening, mammography, and prevention of breast cancer shall be considered the most current other than those issued in or around November 2009. (To see an updated list of the “A” or “B” rated USPSTF Services, visit: xxx.xxxxxxxxxxxxXxxxxxxxxxxxxxxxx.xxxwww.uspreventiveServicestaskforce.org); 2. Immunizations that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention with respect to the individual involved. (Visit the Advisory Committee on Immunization Practices at: xxxx://xxx.xxx.xxx/vaccines/acip/index.htmlhttp://www.cdc.gov/vaccines/acip/index.html); 3. With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration. (Visit HRSA at: xxxx://xxxx.xxxx.xxxhttp://mchb.hrsa.gov); and 4. With respect to women, such additional preventive care and screenings, not described in paragraph 1 above, as provided for in comprehensive guidelines supported by the Health Resources and Services Administration (Visit HRSA at xxxx://xxxx.xxxx.xxxhttp://mchb.hrsa.gov), except for those Services excluded in Exclusions. The Health Plan shall update new recommendations to the preventive benefits listed above at the schedule established by the Secretary of Health and Human Services. We cover medically appropriate preventive health Care Services based on your age, sex or other factors, as determined by your Primary Care Plan Physician in accordance with national preventive health care standards. These Services include the exam, screening tests and interpretation for: 1. Preventive care exams, including: a. Routine physical examinations and health screening tests appropriate to your age and sex; b. Well-woman examinations, including visits to obtain necessary preventive care, and preconception care and prenatal care; and c. Well childcare child care examinations; 2. Routine and necessary immunizations (travel immunizations are not preventive and are covered under Outpatient Care) for children and adults in accordance with Plan guidelines. Childhood immunizations include diphtheria, pertussis, tetanus, polio, hepatitis B, measles, mumps, rubella and other immunizations as may be prescribed by the Commissioner of Health; 3. An annual pap smear, including coverage for any FDA-approved gynecologic cytology screening technology; 4. Low dose screening mammograms, including 3-D mammograms to determine the presence of breast disease is covered as follows: a. One mammogram for persons age 35 through 39; b. One mammogram biennially for persons age 40 through 49; and c. One mammogram annually for person 50 or older; 5. Adjuvant breast cancer screening, including magnetic resonance imaging (MRI), ultrasound, screening, or molecular breast imaging of the breast, if: a. A mammogram demonstrates a Class C or Class D breast density classification; or b. A woman is believed to be at an increased risk for cancer due to family history or prior personal history of breast cancer, positive genetic testing, or other indications of an increased risk for cancer as determined by a woman’s physician or advanced practice registered nurse. 6. Bone mass measurement to determine risk for osteoporosis; 7. Prostate Cancer screening including diagnostic examinations, digital rectal examinations, and prostate antigen (PSA) tests provided to men who are age 40 or older; 8. Colorectal cancer screening in accordance with screening guidelines issued by the American Cancer Society including fecal occult blood tests, flexible sigmoidoscopy, and screening colonoscopy; 9. Cholesterol test (lipid profile); 10. Diabetes screening (fasting blood glucose test); 11. Sexually Transmitted Disease (STD) screening and counseling (including chlamydia, gonorrhea, syphilis and Human Papillomavirus (HPV)), subject to the following: a. Annual chlamydia screening is covered for: i. Women under age 20 if they are sexually active; and ii. Women age 20 or older, and men of any age, who have multiple risk factors, which include: a) Prior history of sexually transmitted diseases; b) New or multiple sex partners; c) Inconsistent use of barrier contraceptives; or d) Cervical ectopy; b. Human Papillomavirus (HPV) testing as recommended for cervical cytology screening by the American College of Obstetricians and Gynecologists; 12. HIV screening and counseling; 13. TB tests; 14. Newborn hearing screenings that include follow up audiological examinations, as recommended by a physician or audiologist, and performed by a licensed audiologist to confirm the existence or absence of hearing loss when ordered by a Plan Provider; 15. Associated preventive care radiological and lab tests not listed above; 16. BRCA counseling and genetic testing is covered at no Cost Share. Any follow up Medically Necessary treatment is covered at the applicable Cost Share based upon type and place of Service; and 17. CT scan of the Thorax when ordered as a preventive for smokers age 55 to 80 years of age. Pursuant to IRS Notice 2019-45, coverage is provided for expanded preventive care Services for labs and screenings without any Cost Sharing requirements such as Copayments, Coinsurance amounts and Deductibles: 1. Retinopathy screening for diabetics 2. HbA1C for diabetics 3. Low density Lipoprotein lab test for people with heart disease 4. INR lab test for liver failure and bleeding disorders Note: Refer to Diabetes Treatment, Equipment and Supplies for coverage of glucose monitoring equipment. Note: Refer to Durable Medical Equipment for coverage of peak flow meters. Note: Refer to Outpatient Care for coverage of non-preventive diagnostic tests and other covered Services. See the benefit-specific limitations immediately below for additional information.;