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.
Standard Plan members
How the benefit works
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.
Who is eligible?
The benefit is available to all non-Medicare primary adults ages 19 and older who are covered by the Standard Plan. Adult members can take advantage of this benefit at a network provider specializing in General Practice, Family Practice, Pediatrics, Internal Medicine, Gerontology, and Obstetrics and Gynecology.
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 woman visits both doctors in the same covered year, only the first routine office visit received will be covered. Females ages 18-65 can receive a Pap test each calendar year at no member cost through PEBA Perks. In years when you are not eligible for an adult well visit, you can still receive a Pap test at no member cost.
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 negotiated rate for an adult well visit. Eligible network providers have agreed to accept this rate as their total fee for an adult well visit. However, the amount you pay in a non-covered year does not apply toward your deductible or coinsurance maximum. Also, the negotiated rate applies to only one well visit each year.
Savings Plan members
Savings Plan members are eligible for one well visit each year at no member cost. The benefit is available to all non-Medicare primary adults ages 19 and older who are covered by the Savings Plan. Adult members can take advantage of this benefit at a network provider specializing in General Practice, Family Practice, Pediatrics, Internal Medicine, Gerontology, and Obstetrics and Gynecology.
How to get the most out of your benefits.
The State Health Plan offers many value-based benefits at no member cost to its primary members through PEBA Perks. Plus, you can set aside money pretax in your MoneyPlus account to pay for your adult well visit. Learn how to coordinate your MoneyPlus and PEBA Perks benefits with your adult well visit below.
Step 1: Set aside money in your MoneyPlus account.
Estimate how much you will spend on your adult well visit in a covered year or a non-covered year. Include this amount when you determine much you should contribute to your MoneyPlus account.
Step 2: Get your preventive screening.
You can receive a biometric screening at no cost through PEBA Perks , which will minimize cost to you at your adult well visit.
Step 3: Have your adult well visit after your preventive screening.
USPSTF A and B recommendations are included as part of an adult well visit. After talking with your doctor during a visit, the doctor can decide which services you need and build a personal care plan for you.
Step 4: Share your preventive screening results with your doctor.
You will receive a confidential report with your screening results, and we recommend you share it with your doctor to eliminate the need for retesting at a well visit. Sharing your results will minimize the cost of your adult well visit.
Step 5: Follow your doctor's recommendations and stay engaged with your health.
We encourage you to take advantage of the other PEBA Perks available to you. If you're eligible, sign up for No-Pay Copay to receive some generic drugs at no cost to you.
Services not included as part of an adult well visit
Services not included as part of the adult well visit are those without an A or B recommendation by the USPSTF. Find these recommendations at www.USPreventiveServicesTaskForce.org. 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.