Well visits may be a key part of preventive care. They can reassure you that you are as healthy as you feel, or prompt you to ask questions about your health. Evidence-supported services, based on United States Preventive Services Task Force (USPSTF) A and B recommendations, are included as part of an adult well visit under the State Health Plan. After talking with your doctor during a visit, the doctor can decide which services you need from the approved USPSTF recommendations and build a personal care plan for you.
Who is eligible
The benefit is available to all non-Medicare primary adults ages 19 and older who are covered by the State Health Plan. Adult members can take advantage of this benefit at a network provider specializing in General Practice, Family Practice, Pediatrics, Internal Medicine and Obstetrics and Gynecology.
Standard Plan members
How the benefit works
The Plan will cover adult well visits beginning January 1, 2019. Adult well visits are subject to copayments, deductibles and coinsurance in covered years. If you have not met your deductible, you will pay the $14 copayment plus the remaining allowed amount for the visit. If you have met your deductible, you will pay the $14 copayment plus your 20 percent coinsurance for the visit.
Eligible female members may use their well visit at their gynecologist or their primary care physician, but not both, in a covered year. If a female visits both doctors in the same covered year, only the first well office visit received will be allowed. See the Cervical cancer screening section below for information about how a Pap test is covered.
Frequency of visits
The Plan will only cover one well visit in covered years, based on the following schedule:
In a non-covered year, you can take advantage of the State Health Plan’s contracted rate for an adult well visit. This means eligible network providers have agreed to accept this amount as their total fee for an adult well visit. The contracted rate may be more than 50 percent less than the provider’s charges. However, the amount you pay in a non-covered year does not apply towards your deductible or coinsurance maximum. Also, the contracted rate applies to only one well visit each year.
Savings Plan members
Beginning January 1, 2019, Savings Plan members' covered well visits will include evidence-supported services based on USPSTF A and B recommendations at an eligible network provider. The Plan will cover a well visit every year for Savings Plan members at no member cost.
How to get the most out of your State Health Plan benefits
The State Health Plan offers many value-based benefits at no member cost to primary members through PEBA Perks. You may continue to take advantage of these services. Learn how the preventive screening and cervical cancer screening benefits work with your adult well visit below.
You can receive a biometric screening at no member cost from a participating screening provider, and the screening includes comprehensive blood work with lipid panels, as well as:
A health risk appraisal;
Blood pressure screening; and
Height and weight measurements.
You will receive a confidential report, and we recommend you share it with your doctor to eliminate the need for retesting at a well visit. Doing this will minimize cost to you, since only a lipid panel and a glucose panel are covered as part of a well visit.
Cervical cancer screening
If you are a female ages 18-65, you can receive a routine Pap test each calendar year. In years in which Standard Plan members are not eligible for an adult well visit, the Standard Plan will cover the cost of the Pap test and the part of the office visit associated with the Pap test. You will be responsible for the remainder of the cost for the visit in those years. You can also receive an HPV test in combination with a Pap test once every five years at no member cost if you are ages 30-65.
Services not included as part of an adult well visit
Other services, including a complete blood count (CBC), EKG, PSA test and basic metabolic panel, if ordered by your physician to treat a specific condition, may still be covered. These services are subject to copayments, deductibles and coinsurance, as well as normal Plan provisions. Follow-up visits and services as a result of your well visit are also subject to normal Plan provisions.