Preventive Care Services for Children

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Covered Preventive Care Services for Children

The cost of many screenings and checkups is covered at 100% with no out of pocket costs for you and those on your plan. Take advantage of preventive care and stop problems before they get serious.

To be covered with no out-of-pocket costs, the service must be:

  • Provided by an in-network doctor or facility (urgent care facility, outpatient clinic or ambulatory surgery center)
  • Filed by your doctor as a preventive care visit
  • Identified as preventive care under the Affordable Care Act (ACA)

Am I eligible for these benefits at 100%?

Find an in-network doctor for preventive care

What else do I need to know?

100% covered services for children

The age and frequency listed below are general recommendations.
Talk to your doctor to find out which of these you should have based on your health.

Click on a service to see any limits or exclusions.

Infants

Anemia (Iron in the Blood)

Who Should Get It: Infants to age 12 months

  • Description: Routine iron supplementation for infants. All infants at age 12 months should be screened for anemia
  • Frequency: May vary based on your child’s health so ask your doctor
  • Exclusions: Over-the-counter (OTC) iron supplements are only covered with a prescription

Bilirubin Screening

Who Should Get It: Newborns

  • Description: Assessment of bilirubin level
  • Frequency: Once
  • More Information: Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth

Cavity Prevention (Prevention of Dental Caries)

Who Should Get It: Infants over 6 months

  • Description: Part of a wellness office visit for children age 6 months to 16 years
    • Primary care clinicians to prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride
    • Primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption
  • Frequency: May vary based on your child’s health so ask your doctor
  • Exclusions: Fluoride varnish services will not be covered beyond the 5th birthday

Congenital Hypothyroidism Screening

Who Should Get It: Newborns

  • Description: Screening for congenital hypothyroidism
  • Frequency: Once
  • More Information: Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth

Critical Congenital Heart Defect Screening

Who Should Get It: Newborns

  • Description: Screening for critical congenital heart defects in newborns
  • Frequency: Once

Hearing Loss Screening

Who Should Get It: Newborns

  • Description: Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth
  • Frequency: Once

Phenylketonuria (PKU) Screening

Who Should Get It: Newborns

  • Description: Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth
  • Frequency: Once

Preventive Medication for Gonorrhea

Who Should Get It: High-risk newborns

  • Description: Prophylactic (preventive) ocular topical medication for all newborns to prevent gonococcal ophthalmia neonatorum (gonorrhea)
  • Frequency: Once
  • More Information: This medication is generally given to a newborn at the birth facility

Sickle Cell Disease Screening

Who Should Get It: Newborns

  • Description: Screening for sickle cell disease (Hemoglobinopathies) in newborns
  • Frequency: Once
  • More information: Service is typically performed in the birth facility or as part of a wellness office visit in the event of a home birth

 Children

Alcohol and Drug Use Assessment

Who Should Get It: From age 11

  • Description: Assessment of alcohol and drug use in children, adolescents and teens
  • Frequency: May vary based on your child’s health so ask your doctor

Anticipatory Guidance

Who Should Get It: Under age 18

  • Description: Directed information from your child’s provider to the parent and/or child regarding developmentally appropriate topics that may not be currently present but might be anticipated. The goals are to inform a family about common situations that may be encountered at each stage of development, prevent unnecessary injuries and allay common misunderstandings. This may include issues such as obesity, tobacco use, safety equipment (e.g., bicycle helmets), and media exposure (e.g., appropriate choices about internet and TV use, movies, music, etc.)
  • Frequency: May vary based on your child’s health so ask your doctor

Autism Screening

Who Should Get It: 18 and 24 months

  • Description: Screening for autism in children
  • Frequency: May vary based on your child’s health so ask your doctor

Behavioral Counseling to Prevent Skin Cancer

Who Should Get It: Age 10 - 24 with fair skin

  • Description: Counseling children, adolescents and young adults age 10–24 who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer
  • Frequency: May vary based on your child’s health so ask your doctor; considered part of wellness office visit

Cavity Prevention (Prevention of Dental Caries)

Who Should Get It: Children under 16

  • Description: Part of a wellness office visit for children age 6 months to 16 years
    • Primary care clinicians to prescribe oral fluoride supplementation starting at age 6 months for children whose water supply is deficient in fluoride
    • Primary care clinicians apply fluoride varnish to the primary teeth of all infants and children starting at the age of primary tooth eruption
  • Frequency: May vary based on your child’s health so ask your doctor
  • Exclusions: Fluoride varnish services will not be covered beyond the 5th birthday

Cholestorol Screening (Dyslipdemia)

Who Should Get It: Under age 18

  • Description: Cholesterol screening in children
  • Frequency: May vary based on your child’s health so ask your doctor

Developmental Screening

Who Should Get It: 9, 18 and 30 months

  • Description: Screening to assess developmental progress in children
  • Frequency: May vary based on your child’s health so ask your doctor

Developmental Surveillance

Who Should Get It: Under age 18

  • Description: Monitoring developmental health in children
  • Frequency: May vary based on your child’s health so ask your doctor

Hearing Screening (Beyond Newborn Screening)

Who Should Get It: Under 18

  • Description: Screening for hearing health in children
  • Frequency: May vary based on your child’s health so ask your doctor

Lead Screening

Who Should Get It: Children up to age 7

  • Description: Screening for lead presence in young children
  • Frequency: May vary based on your child’s health so ask your doctor

Obesity Screening and Counseling

Who Should Get It: Children age 6 and older

  • Description: Screening for obesity; doctor should offer/refer to comprehensive, intensive behavioral interventions to promote improvement in weight status
  • Frequency: May vary based on your child’s health so ask your doctor
  • More information: Includes 30 nutritional counseling visits

Oral Health Check

Who Should Get It: Under age 18

  • Description: Screening of child’s mouth to identify oral issues such as tooth decay or delayed teeth
  • Frequency: May vary based on your child’s health so ask your doctor

Psychosocial/Behavioral Assessment

Who Should Get It: Under age 18

  • Description: Assessment of child’s psychosocial and behavioral development
  • Frequency: May vary based on your child’s health so ask your doctor

Tobacco Use for Children and Adolescents

Who Should Get It: School-age children and adolescents

  • Description: Provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents
  • Frequency: May vary based on your child’s health so ask your doctor
  • Exclusions: Applicable only for members over age 5

Tuberculin Test 

Who Should Get It: Under age 18

  • Description: Skin test to detect tuberculosis (TB) in children
  • Frequency: May vary based on your child’s health so ask your doctor

Vision Screening

Who Should Get It: Under age 18

  • Description: Vision screening at least once in all children aged 3 to 5 years to detect amblyopia (also known as 'lazy eye') or its risk factors.
  • Frequency: For over age 5, talk to you doctor about how often your child needs a vision screening

Adolescents and Teens

Anxiety Screening

Who Should Get It: Female adolescents

  • Description: Screening for anxiety in female adolescents, including those who are pregnant or postpartum
  • Frequency: May vary based on your health so ask your doctor

Behavioral Counseling Interventions for Healthy Weight and Weight Gain in Pregnancy

Who Should Get It: Pregnant adolescents

  • Description: Clinicians offer pregnant persons effective behavioral counseling interventions aimed at promoting healthy weight gain and preventing excess gestational weight gain in pregnancy.
  • Frequency: May vary based on your health so ask your child’s doctor

Behavioral Counseling to Prevent Skin Cancer

Who Should Get It: Age 10 - 24 with fair skin

  • Description: Counseling children, adolescents and young adults age 10–24 who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer
  • Frequency: May vary based on your child’s health so ask your doctor; considered part of wellness office visit

Chlamydia Screening

Who Should Get It: Sexually active adolescents 15 and older who are at increased risk of infection

  • Description: Screening for Chlamydia in sexually active adolescents
  • Frequency: May vary based on your health so ask your doctor

Contraception: Education and Contraceptive Methods

Who Should Get It: Female adolescents who are sexually active or thinking about becoming sexually active

  • Description: Education and counseling related to contraceptives and sterilization for women with reproductive capacity; surgical sterilization (except hysterectomies, which are not performed solely for sterilization)
  • Frequency: May vary based on your health so ask your doctor
  • More information:
    • Talk to your child's doctor to determine which of these contraceptive method is right for her
    • Anesthesia services will pay at 100% only for sterilization
    • Certain services for contraceptive device insertion and removal, such as ultrasounds to confirm IUD placement will pay at 100%
    • Pregnancy tests prior to the initiation of contraceptive will pay at 100%
    • The following contraceptive methods (devices and associated procedures, such as device removal, and pharmaceutical contraceptives) for women with reproductive capacity:
      • Cervical caps
      • Diaphragms
      • Emergency contraception (i.e., morning after pill, Plan B, ella)
      • Fertility app
        • Effective 8.1.22, one annual subscription to Natural Cycles covered per benefit period. No additional supplies/services are covered. Natural Cycles is currently the only FDA-cleared fertility app.
        • Members must download the Member Claim Form or the State Health Plan Claim Form to submit and include the following:
          • the Natural Cycles receipt. Write the CPT code 99199 and diagnosis code Z30.8 on the receipt.
          • a prescription from an in-network provider that includes the name of the app, Natural Cycles fertility app
      • Injections (only covered as preventive for Medoxyprogesterone Acetate 150 mg, which is the only drug and dosage used for contraception)
      • Implantable rods
      • IUDs
      • Oral contraceptives (all generic contraceptives will be covered as preventive; brand oral contraceptives will continue to require member cost sharing (e.g., deductible, copay, and/or coinsurance) View a complete list of preventive oral contraceptives
      • OTC contraceptives (female condoms, all products; sponges, all products; spermicides, all products, male condoms effective 1.1.23)
      • Sterilization procedures including tubal ligation (tying of fallopian tubes) and salpingectomy (removal of fallopian tubes). Salpingectomy for sterilization purposes will be covered as preventive effective 7.1.22
      • Trans-dermal contraceptives (i.e., contraceptive patches)
      • Vaginal rings (i.e., Nuvaring)
    • Diaphragms are available only through the pharmacy and IUDs are available only through a professional provider
    • If there is a medical reason you cannot take a generic contraceptive, your doctor should review this ACA Copay Waiver Criteria; if you meet these criteria, they can submit this information on this fax form
  • Exclusions:
    • Sterilization coverage applies to all places of service, with the exception of the Emergency Room; separately billed services are not covered under preventive services and are subject to the normal benefits based on place of service
    • Diaphragms, vaginal rings, contraceptive patches, female condoms, sponges, spermicides, and emergency contraception are available only with a prescription

Depression Screening

Who Should Get It: Children from age 12

  • Description:Screening for major depressive disorder in adolescents aged 12 to 18 years. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate follow-up
  • Frequency: May vary based on your child’s health so ask your doctor; part of any problem or preventive office visit

Gonorrhea screening

Who Should Get It: Sexually active adolescents 15 and older who are at increased risk of infection

  • Description: Screening for Gonorrhea in sexually active adolescents
  • Frequency: May vary based on your health so ask your doctor

Hepatitis B Screening

Who Should Get It: Adolescents at high risk of infection

  • Description: Screening for Hepatitis B in adolescents at high risk of infection
  • Frequency: May vary based on your health so ask your doctor

HIV Infection Prevention with Pre-exposure Prophylaxis

Who Should Get It: Adolescents at high risk of acquiring HIV

  • Description: Offer preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons who are at high risk of HIV acquisition
  • More Information: Medications covered at 100%: emtricitabine/tenofovir (generic Truvada). For members who are clinically unable to utilize generic Truvada, brand Truvada, Viread, or Descovy may be made available by completing this form and faxing it to the number on the bottom of this document.
  • Frequency: May vary based on your health so ask your doctor
  • Effective: at renewal on or after July 1, 2020

Intimate Partner Violence Screening

Who Should Get It: Female adolescents

  • Description: Doctor should provide or refer women who screen positive to intervention services
  • Frequency: At least annually

Obesity Screening and Counseling

Who Should Get It: Children Age 6 and Older

  • Description: Screening for obesity; doctor should offer/refer to comprehensive, intensive behavioral interventions to promote improvement in weight status
  • Frequency: May vary based on your child’s health so ask your doctor
  • More information: Includes 30 nutritional counseling visits

Sexually Transmitted Infection (STI) / HIV Screening and Behavioral Counseling to Prevent STIs

Who Should Get It: Sexually active adolescents and teens

  • Description: Behavioral counseling for sexually active adolescents and teens at increased risk for sexually transmitted infections (STIs) and HIV
  • Frequency: May vary based on your child’s health so ask your doctor

Syphilis Screening

Who Should Get It: Adolescents at high risk of infection

  • Description: Screening for Syphilis in those at increased risk of infection
  • Frequency: May vary based on your health so ask your doctor

Tobacco Use Counseling for Children and Adolescents

Who Should Get It: School-age children and adolescents

  • Description: Provide interventions, including education or brief counseling, to prevent initiation of tobacco use in school-aged children and adolescents
  • Frequency: May vary based on your child’s health so ask your doctor
  • Exclusions: Applicable only for members over age 5

Well-child visits

Who Should Get It: Female adolescents

  • Description: For female adolescents to get recommended preventive services that are age and developmentally appropriate. This well-child visit should, where appropriate, include other preventive services listed on this page
  • Frequency: Annual, although Health and Human Services recognizes that several visits may be needed to obtain all necessary recommended preventive services, depending on an adolescent's health status, health needs and other risk factors

Immunizations

Infants and Children

The following are the recommended vaccines for children that are covered with no out of pocket cost. Doses, recommended ages and recommended populations vary.

See your doctor and refer to the CDC’s posted schedule of immunizations.

  • Dengue Fever
  • Diphtheria, Tetanus-Acellular, Pertussis (DTap)
  • Haemophilus Infuenzae Type B (Hib)
  • Hepatitis A
  • Hepatitis B
  • Inactivated Poliovirus (IPV)
  • Influenza (Flu)
  • Measles, Mumps, Rubella (MMR)
  • Pneumococcal
  • Rotavirus
  • Varicella (Chicken Pox)

Adolescents and Teens

  • Human papillomavirus (HPV)
  • Influenza (flu)
  • Meningococcal
  • Tetanus, diphtheria, acellular pertussis (Tdap)
The Affordable Care Act (ACA) has identified certain services as preventive care to be paid at 100%.

 

  • These benefits are available for members of non-grandfathered individual health insurance plans.
  • If you get benefits from your employer, you may also have these benefits. If your Summary of Benefits section of your Benefit Booklet contains PREVENTIVE CARE covered under federal law, then you have these benefits at no charge IN-NETWORK.
  • These benefits are currently in effect unless otherwise noted.
  • Check your Benefit Booklet for details on other preventive care benefits.
  • This information is a reference tool and does not guarantee payment of any claims.
  • For transgendered individuals, you have access to medically appropriate preventive services.
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  • Preventive Care