1. What Services are Preventive?
All MUS health options provide preventive care coverage that complies with the federal health care reform law, the Patient Protection and Affordable Care Act (PPACA). Services designated as preventive care include:
- periodic wellness visits
- certain designated screenings for symptom free or disease free individuals, and
- designated routine immunizations.
When this preventive care is provided by in-network providers it is reimbursed at 100% of the allowed amount, without application of deductible, coinsurance, or co-pay.
The PPACA has used specific resources to identify the preventive services that require coverage: U.S. Preventive Services Task Force (USPSTF) A and B recommendations and the Advisory Committee on Immunization Practices (ACIP) recommendations adopted by the Center for Disease Control (CDC). Guidelines for preventive care for infants, children, and adolescents, supported by the Health Resources and Services Administration (HRSA), come from two sources: Bright Futures Recommendations for Pediatric Health Care and the Uniform Panel of the Secretary’s Advisory Committee on Heritable
Disorders in Newborns and Children.
1. Important Tips
1. Accurate coding for preventive services by your health care provider is the key to accurate reimbursement by your health care plan. All standard correct coding practices should be observed.
2. Also of importance is the difference between a “screening” test and a diagnostic, monitoring or surveillance test. A “screening” test done on an asymptomatic person is a preventive service, and is considered preventive even if the test results are positive for disease, but future tests would be diagnostic, for monitoring the disease or the risk factors for the disease. A test done because symptoms of disease are present is not a preventive screening.
3. Ancillary services directly associated with a “screening” colonoscopy are also considered preventive services. Therefore, the procedure evaluation office visit with the doctor performing the colonoscopy, the ambulatory facility fee, anesthesiology (if necessary), and pathology will be reimbursed as preventive provided they are submitted with accurate preventive coding.
Covered Preventive Services
Infant through age 17
|Age 0 months through 4 yrs (up to 14 visits)
Age 5 yrs through 17 yrs (1 visit per benefit plan year)
|Adult Routine Exam
Exams may include screening/counseling and/or risk factor reduction interventions for depression, obesity, tobacco use/abuse, drug and/or alcohol use/abuse
|Age 18 yrs through 65+ (1 visit per benefit plan year)|
|Anemia Screening||Pregnant Women|
|Bacteriuria Screening||Pregnant Women|
|Breast Cancer Screening (mammography)||Women 40+ (1 per benefit plan year)|
|Cervical Cancer Screening (PAP)||Women age 21 - 65 (1 per benefit plan year)|
|Cholesterol Screening||Men age 35+ (age 20 - 35 if risk factors for coronary heart disease are present)
Women age 45+ (age 20 - 45 if risk factors for coronary heart disease are present)
|Colorectal Cancer Screening
|Fecal occult blood testing; 1 per benefit plan year OR
Sigmoidoscopy; every 5 yrs OR
Colonoscopy; every 10 yrs
|Prostate Cancer Screening (PSA) age 50+||1 per benefit plan year (age 40+ with risk factors)|
|Osteoporosis Screening||Post menopausal women 65+, or 60+ with risk factors (1 bone density x-ray (DXA))|
|Abdominal Aneurysm Screening||Men age 65 - 75 who have ever smoked (1 screening by ultrasound per plan year)|
|Diabetes Screening||Adults with high blood pressure|
|HIV Screening||Pregnant women and others at risk|
|RH Incompatibility Screening||Pregnant women|
|Diptheria, tetanus, pertussis (DTaP) (Tdap)(TD), Haemophilus influenza (HIB), Hepatitis A & B, Human Papillomavirus (HPV), Influenza, Measles, Mumps, Rubella (MMR), Meningococcal, Pneumococcal (pneumonia), Poliovirus, Rotavirus, Varicella (smallpox), Zoster (shingles)
If needed, see immunization schedules on Center for Disease Control (CDC) website