Preventive Health
Did you know that Horizon Blue Cross Blue Shield of New Jersey provides full coverage for certain preventive services at no cost to you under the Affordable Care Act?
As long as you and your covered family member(s) get preventive care from an in-network doctor or health care professional, and the only reason for your visit is preventive care, the services are covered with no out-of-pocket costs. Here are the services you and your covered dependents are entitled to with no out-of-pocket costs:
Newborn Screenings
- Hearing
- Phenylketonuria (PKU) (blood test for genetic disorder)
- Sickle cell anemia
- Standard metabolic screening panel for inherited enzyme deficiency diseases
- Thyroid disease
Childhood Screenings and Counseling
- Behavioral assessments for children of all ages
- Counseling and fluoride varnish, provided in a primary care setting, for ages birth through 6 years to prevent dental cavities
- Depression screenings recommended between ages 12 to 18 years
- Developmental screenings, from birth through 2 years
- Laboratory screenings
- Dyslipidemia
- Iron deficiency anemia
- Lead exposure
- Medical evaluation well visits
- Height, weight and body mass measurements
- Oral health risk assessments
- Visual impairment screenings recommended between ages 3 to 5 years
- Obesity (with possible referral to weight management counseling)
- Tobacco use interventions
- Tuberculin testing
Immunizations for Children (from birth to 7 years) and Adolescents (ages 8 to 17 years)
- Haemophilus influenzae type B
- Hepatitis A
- Hepatitis B
- Human papillomavirus (HPV; adolescent)
- Influenza
- Measles, mumps, rubella (MMR)
- Meningococcal
- Pneumococcal
- Poliovirus (inactivated)
- Rotavirus
- Tetanus, diphtheria, pertussis (Td, Tdap)
- Varicella (chicken pox)
Adult Screenings and Counseling
- Alcohol and substance use counseling
- Cholesterol abnormalities for ages 20 years and older
- Colorectal cancer screenings, including colonoscopies every 10 years (ages 50 years and older at average risk, and continuing until age 75 years)
- Counseling for the prevention of sexually transmitted diseases (STDs)
- Depression screenings
- Diabetes screenings
- Hepatitis B and C virus screenings, for persons at high risk for infection
- High blood pressure screenings
- Lung cancer screenings (ages 55 years and older with a history of smoking for 30 years)
- Nutritional counseling
- Obesity
- Skin cancer behavioral counseling
- Smoking and tobacco cessation counseling
Health Screenings, Preventive and Pregnancy-Related Services for Women
- Breast-feeding support, supplies and counseling, including costs for obtaining breast-feeding equipment
- Gestational diabetes screening for all pregnant women
- Screening pregnant women for:
- Iron-deficiency anemia
- Bacteria in urine
- Hepatitis B virus
- Rh incompatibility
- Preeclampsia
- Well-woman visits, including preconception counseling and prenatal care as set forth in the U.S. Preventive Services Task Force (USPSTF) recommendations
- Cervical cancer screening, including Pap tests, for women ages 21 to 65 years
- Domestic violence screening and counseling
- U.S. Food and Drug Administration (FDA)-approved sterilization procedures and contraceptive methods
- Genetic counseling evaluation and lab test, with prior authorization, for the breast cancer gene BRCA (breast cancer susceptibility gene)
- Counseling for prevention strategies for women at high risk for breast cancer
- Human papillomavirus DNA testing for women ages 21 years and older
- Mammography (film and conventional 2D) for women, annually, beginning at age 40 years
- Osteoporosis screening, ages 65 years and older
- Sexually transmitted disease (STD) counseling and screening including HIV, gonorrhea, chlamydia and syphilis for all sexually active women
Health Screening for Men
- Screening for abdominal aortic aneurysm in men ages 65 to 75 years who have ever smoked
Preventive Drugs at an Appropriate Age, Gender or Risk Status
The following drugs and supplements are covered, without cost share, if you have pharmacy coverage through your Horizon BCBSNJ plan, and the medications, even if over-the-counter, are prescribed by a health care professional and filled at a network pharmacy:
- Aspirin to prevent cardiovascular disease for men ages 45 to 79 years
- Aspirin to prevent cardiovascular disease for women ages 55 to 79 years
- Aspirin to prevent preeclampsia for pregnant women, after 12 weeks of gestation
- FDA-approved female contraception methods
- Fluoride supplements for children from birth through 6 years
- Folic acid supplements for women planning or capable of pregnancy
- Iron supplements for children from birth through 1 year
- Risk-reducing breast cancer medications for women, with prior authorization
- Tobacco cessation medications (may require prior authorization)
Preventive Health Guidelines: Birth to age 21 years
Discuss these guidelines with your doctor and use them in planning to get preventive care services that are appropriate for you and your family.
ID: EC001756B (0619)
Preventive Health Guidelines: Adults
Discuss these guidelines with your doctor and use them in planning to get preventive care services that are appropriate for you and your family.
ID: EC001756A (0220)
This is only a brief summary of preventive service recommendations issued as part of the Federal Interim Final Rules for Group Health Plans and Health Insurance Issuers Relating to Coverage of Preventive Services under the Patient Protection and Affordable Care Act (PPACA). Please visit HealthCare.gov for more information
- Recommendations for immunizations were obtained from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC). Only the member’s health care professional can determine which immunizations are required.
- Recommendations for screenings and counseling services were obtained from the United States Preventive Services Task Force (USPSTF), a division of the U.S. Department of Health & Human Services’ (HHS) Agency for Healthcare Research and Quality (AHRQ).
- This document is for informational purposes. The information should not be construed as legal or medical advice. Members should direct questions about the screening tests, immunizations, counseling or supplements to their health care professionals.
- The information provided is subject to change because it is generally expected that continued guidance from the USPSTF will be released affecting recommended coverage of preventive services under the Affordable Care Act (ACA).
- For some members, state mandates for certain preventive services may apply rather than federal mandates, if the state mandates are stricter
- Requirements under PPACA became effective at the beginning of each plan year (or for individual market coverage, policy year) on or after September 23, 2010.
- PPACA permits health coverage that was effective on or before March 23, 2010 to be “grandfathered&8221; under certain circumstances so that it does not have to comply with certain provisions in PPACA. If the member’s plan is grandfathered, these benefits may not be available to the member
- If the member’s Horizon BCBSNJ health plan uses a network of participating doctors and other health care professionals, or the member’s Horizon BCBSNJ health plan is a non-network based health plan (such as an Indemnity Plan), the member’s plan provides these preventive services at no cost sharing ONLY through in-network doctors and other health care professionals.
- If the member’s Horizon BCBSNJ health plan offers in-network and out-of-network coverage, preventive care services received out of network will continue to be covered under the member’s current cost sharing arrangement.
- A doctor may provide a preventive service, such as cholesterol screening, as part of an office visit. The member may have out-of-pocket costs for the office visit, if the preventive service is not the primary purpose of the visit or if the doctor bills the member for the office visit separately from the preventive care.
