What are the Preventative care guidelines?

The guidelines list the types of care screenings and exams needed for your particular age and gender.

• For infants and young children, the guidelines focus on physical and mental development, immunizations, nutrition, and safety.
• For children and young adults, the focus is on maintaining or developing healthy lifestyle habits and eliminating high-risk behaviors.
• For adults, the focus continues to be on eliminating high-risk behaviors, however, screening for chronic and/or life-threatening disease becomes more important.

Does my health insurance cover these preventive care exams?

The health care reform Affordable Care Act (ACA) requires that plans begin providing benefits for preventive services with no member cost share, such as co-payments, deductibles, and coinsurance, when services are performed by in-network providers. However, some plans are not required to comply with this mandate.

If your contract is affected by this change, Wellmark will provide first-dollar coverage for covered preventive services performed by in network providers. Claims for preventive services from out-of-network providers will process using the benefits specified in your benefits policy or coverage manual, and will continue to apply member cost-sharing amounts.

The change will become effective in stages over the next several months, depending on your health plan. For more details about your preventive benefits, contact Customer Service at the number on your identification card.

What is a health maintenance exam (HME)?

A health maintenance exam is what was commonly known as a “routine” or “annual” physical. You might have heard of an “annual physical.” Your health benefits, however, do not necessarily cover “annual” physicals. Instead, your benefits cover periodic health maintenance exams.

How is the frequency of health maintenance exams determined?

Our guidelines are based on recommendations from the American Academy of Pediatrics, The American Academy of Family Practice, the American College of Obstetrics and Gynecology, and the Center for Disease Control, among others. Wellmark’s guidelines are reviewed annually. We provide benefits for health maintenance exams at time frames that are considered most appropriate given your age and gender.

Read Part 2 about female exams.