PreventiveCare:ServicesCoveredUndertheAffordableCareAct

Thisistoprovideyouwithalistofpreventivecareservicescoveredinaccordancewiththe
federalAffordableCareAct.TheseservicesarecoveredbyallhealthplansofferedbyHarvard
Pilgrimanditsaffiliates,exceptgrandfatheredplans.1Whenyouobtaintheseservicesfrom
anInNetworkPlanProvider,theyarecoveredfreeofcharge;thereisnoMemberCostSharing
required.However,ifyourplanoffersOutofNetworkbenefits,youwillusuallyhavetopay
MemberCostSharingifyoureceivepreventivecarefromaNonPlanProvider.
Thelistonthefollowingpagesincludesonlytheservicesandtestsrequiredunderthe
AffordableCareAct.Yourplanmaycoveradditionalpreventiveservicespurchasedbyan
employerorrequiredtobeprovidedunderstatelaw.PleaseseeyourBenefitHandbookand
ScheduleofBenefitsfortheseservices.

WhatisPreventiveCare?

Preventivecareiscareyoureceivewhenyou'rehealthyandsymptomfree,suchasroutine
checkups,screeningsandimmunizations.
Diagnosisandtreatmentaredifferentfrompreventivecare.Theyinvolvetestingor
treatmentforasymptomorhealthissueyoualreadyhave,suchasanexistingillnessor
injury.Whenadoctortakesstepstodiagnoseortreatyourhealthcondition,youwillbe
responsibleforMemberCostSharingasstatedinyourplan.
Tolearnmore,viewthepreventivecarepresentationinourmemberLearningCenter,
availableatwww.harvardpilgrim.org/learningcenter.

HarvardPilgrimincludesHarvardPilgrimHealthCare,HarvardPilgrimHealthCareofNewEngland,Harvard
PilgrimHealthCareofConnecticutandHPHCInsuranceCompany.IfyouhaveaGrandfatheredPlantherewillbea
noticetothateffectinyourScheduleofBenefits.

Form No. 1541

Page 1
09/2015


PreventiveCareServices
ThepreventiveservicesandtestslistedbelowarecoveredwithnoMemberCostSharingwhen
receivedfromaPlanProvider.
AdultsandChildren

AdultsOnly

Routinephysicalexaminations
Alcoholmisusescreeningand
counseling(primarycarevisitsonly,
beginningatage11)
Cholesterolscreening
Depressionscreening(adults,children
ages1218,primarycarevisitsonly)
Dietbehavioralcounseling(includedas
partofannualvisitandintensive
counselingbyprimarycarecliniciansor
bynutritionistsanddieticians)
HemoglobinA1c
HepatitisBscreeningforpeopleathigh
riskofinfection
HepatitisCtesting(formembersborn
between1945through1965)
Immunizations,includingflushots(flu
shotsatage19andaboveatadoctors
officeorpharmacy;underage19ata
doctorsoffice)
Obesityscreeningandcounseling
(adultsandchildren,inprimarycare
settings)
Sexuallytransmitteddiseases(STDs)
screeningsandcounseling(adolescents,
adultsandpregnantwomen)
Tobaccousescreeningandcounseling,
includingsmokingcessationcounseling
andFDAapprovednicotine
replacementtherapy(primarycare
visitsonly)
Totalcholesteroltests

WomenOnly

Form No. 1541

Aspirinforthepreventionofheart
diseasewhenprescribedbyahealth
careprovider
Bloodpressurescreening(adults
withoutknownhypertension)
Colorectalcancerscreening,including
colonoscopy,sigmoidoscopyandfecal
occultbloodtest
Diabetesscreenings
HIVscreeningandcounseling
Lungcancerscreeningforadultsages
55to80whohavea30packperyear
smokinghistoryandcurrentlysmokeor
havequitwithinthepast15years
VitaminDsupplementsforthe
preventionoffallswhenprescribedbya
healthcareprovidertocommunity
dwellingmembersbeginningatage65

Aspirin(81mg/day)forwomenwhoare
atleast12weekspregnantandathigh
riskforpreeclampsia
BRCA1or2geneticcounseling,
evaluationandtestingforwomenwith
afamilyhistoryassociatedwith
increasedriskofmutation
Breastcancerchemoprevention
(counselingonlyforwomenathighrisk
forbreastcancerandlowriskfor
adverseeffectsofchemoprevention)
Breastcancerscreening,including
mammogramsandcounselingfor
geneticsusceptibilityscreening
Page 2
09/2015

Breastcancerriskreducing
medications,suchasRaloxifineand
Tamoxifen,forwomenatincreasedrisk
forbreastcancerandatlowriskfor
adversemedicationeffects
Breastfeedingprimarycare
interventions(applicabletopregnant
womenandnewmothers),including
electricandmanualbreastpumps,
lactationclassesandsupportat
prenatalandpostpartumvisits,and
newbornvisits
Cervicalcancerscreening,includingpap
smears
Comprehensivelactationsupport,
counseling,andcostsofrenting
breastfeedingequipment
Contraceptivemethodsapprovedby
theFDA2,sterilizationproceduresand
contraceptivepatienteducationand
counseling(contraceptivescovered
withnomembercostsharinginclude
genericsandbrandnamedrugswithno
genericalternative,including
emergencycontraceptives.)
Folicacidsupplements(women
planningorcapableofpregnancyonly)
Gestationaldiabetesscreening
HPV(humanpapillomavirus)testing
Interpersonalanddomesticviolence
counselingandscreenings
Irondeficiencyanemia(pregnant
womenatprenatalvisits)
Microalbuminuriatest(pregnant
women)
Osteoporosisscreening(screeningto
beginatage50forwomenatincreased
risk)
Ovariancancersusceptibilityscreening

MenOnly

Abdominalaorticaneurysmscreening
(formales6575onetimeonly,ifever
smoked)

ChildrenOnly

Plansprovidedbycertainreligiousemployersmay
beexemptfromcoveringcontraceptiveservices.
PleaseseeyourScheduleofBenefits.

Form No. 1541

Overthecountercontraceptiveitems
suchasspongesandspermicides,when
prescribedbyahealthcareprovider
Rh(D)incompatibility,screening
(pregnantwomen)
RoutineOB/GYNexaminations
Routineoutpatientprenataland
postpartumvisits

Autismscreening(forchildrenat18and
24monthsofage;primarycare
settings)
Behavioralassessments(childrenofall
ages;developmentalsurveillance,in
primarycaresettings)
Congenitalhypothyroidism(screening
fornewbornsonly)
Dyslipidemiascreening(forchildrenat
highriskforhigherlipidlevels)
Fluorideoralsupplementationfor
childrentoage5Note:Coveragefor
oralfluoridesupplementationisonly
providedifyourplanincludes
outpatientpharmacycoverage.
Fluoridevarnishforchildrentoage5
only,whenappliedbyprimarycare
providers,includingpediatricians.
Maximumoffourfluoridevarnish
applicationsarecoveredperyear.
Hearingscreening(screeningfor
newbornonly,primarycaresettings)
Irondeficiencyprevention(primarycare
counselingforchildrenages6to12
monthsonly)
Leadscreening(childrenatrisk)

Page 3
09/2015

Phenylketonuriascreening(newborns
before7daysold)
Sicklecelldisease,screening(screening
atbirthandfirstnewbornvisit)

Tuberculosisskintesting
Visionscreening(childrentoage5only)

Underfederallawthelistofpreventiveservicesandtestscoveredunderthisbenefitmay
changeperiodicallybasedontherecommendationsofthefollowingagencies:

a.GradeAandBrecommendationsoftheUnitedStatesPreventiveServicesTaskForce;

b.Withrespecttoimmunizations,theAdvisoryCommitteeonImmunizationPracticesofthe
CentersforDiseaseControlandPrevention;and

c.Withrespecttoservicesforwoman,infants,childrenandadolescents,theHealthResources
andServicesAdministration

InformationontherecommendationsoftheseagenciesmaybefoundonthewebsiteoftheUS
DepartmentofHealthandHumanServicesat:

https://www.healthcare.gov/whataremypreventivecarebenefits/#part=1

HarvardPilgrimwilladdordeleteservicesfromthislistofpreventiveservicesandtestsin
accordancewithchangesintherecommendationsoftheagencieslistedabove.Youcanfinda
listofthecurrentrecommendationsforpreventivecareonHarvardPilgrimswebsiteat
www.harvardpilgrim.org.

Form No. 1541

Page 4
09/2015