Preventive services – children and adolescents

These services may or may not be covered by all CoOportunity Health plans. Please see your plan documents for your own coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.

Administrative process

No prior authorization is required for Preventive Services for children and adolescents.

Routine Preventive Services are routine healthcare that includes screenings, check-ups and patient counseling to prevent illness, disease, or other health problems before symptoms occur.

• These services are covered at your preventive benefit level.
• These services covered as routine preventive services are derived from:
  • The US preventive Services Task Force, A and B Recommendations
  • The Affordable Care Act mandates

To view preventive care guidelines based on age and gender, please see Related content at right.

Indications that are Covered

The following lists, though not all inclusive, detail services eligible for coverage under the Preventive Services Benefit.

Screenings and assessments during a routine, preventive office visit for:

• Alcohol, drug, and tobacco use (for adolescents)
• Autism specific screening with instruments such as the M-CHAT (for children at 18 and 24 months)
• Behavioral issues, including depression screening for adolescents ages 12-18
• Developmental screening (for children under age 3, and surveillance throughout childhood)
• Hearing screening with basic audiometry
• Vision screening with an instrument such as the Snellen chart
• Height, weight and body mass index measurements
• Medical history
• Obesity screening for children 6 years and older to determine wheteher to offer or refer the child to comprehensive, intensive behavioral interventions to promote improvement in weight status.
• Oral health (risk assessment for young children)
• Newborn hearing screening
• Newborn screening for hemoglobinopathies, phenylketonuria, and hypothyroidism

Counseling during a routine, preventive office visit for:

• Fluoride supplementation for children without fluoride in their water source.
• Sexually transmitted infection (STI) prevention for adolescents at higher risk.
• Iron supplementation for children ages 6 to 12 motnhs at risk for anemia.
• Skin cancer behavioral counseling for children, adolescents, and young adults ages 10 to 24 years who have fair skin about minimizing their exposure to ultraviolet radiation to reduce risk for skin cancer. (This does not include examinations, testing or treatment).
• Tobacco use and provide tobacco cessation interventions for those who sue tobacco.

Medications and supplements:

Gonorrhea preventive medication for the eyes of all newborns (this is done in the hospital at birth).        

These medications are covered with a prescription from your medical practitioner:

• Oral fluoride supplementation (where water source does not contain fluoride) for children ages 6 months to preschool
• Iron supplementation (for children at increased risk iron-deficiency-anemia) for children aged 6-12 months

Immunizations:

From birth to age 18, doses, recommended ages, and recommended populations vary. Please see related content at the right for link to Immunization policy.

• Diphtheria, pertussis, tetanus (DPT, Tdap)
• Haemophilus influenzae type b
• Hepatitis A , Hepatitis B
• Human papillomavirus (HPV)
• Inactivated poliovirus
• Influenza (flu)
• Measles, mumps, rubella (MMR)
• Meningococcal (meningitis)
• Pneumococcal (pneumonia)
• Rotavirus
• Varicella (chicken pox)

Additional covered testing that may be ordered during a routine, preventive office visit but done separately:

• Pap test for cervical dysplasia (for sexually active females)
• Lipid disorders (dyslipidemia screening for children at higher risk)
• Hematocrit or hemoglobin
• HIV (for adolescents at higher risk)
• Lead (for children at risk of exposure)
• Tuberculin testing (for children at higher risk of tuberculosis)
• Newborn metabolic screening (usually takes place in the hospital)

Services that are Not Covered

The following list, though not all inclusive, details services not eligible for coverage at any benefit level:

• Over the counter tests not ordered by your primary medical provider.
• Any supplements (except as listed above under "Medications and Supplements" above) recommended at a preventive care visit.
• Preventive services or screenings including, but not limited to exams, lab tests, x-rays, received from or ordered by:
  • Non-contracted, mobile, outpatient screening entities
  • A non-medical care provider (e.g., naturopath)

The following list, though not all inclusive, details services not eligible for coverage under the Preventive Services benefit because they are considered diagnostic:

• Genetic testing, except state mandated tests in the newborn metabolic screening.
• Referrals to specialists for evaluation of findings during routine preventive screening.

Routine Preventive Services are routine healthcare that includes screenings, check-ups and patient counseling to prevent illness, disease, or other health problems before symptoms occur.

Diagnostic services are services are used to help a provider understand symptoms, diagnose illness, and decide what treatment may be needed. They may be the same tests that are listed as preventive services, but they are being used as diagnostic services. These services are not preventive if received as part of a visit to diagnose, monitor an established condition, or treat an illness or injury. When that occurs, standard deductibles, co-pays or coinsurance apply.

If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive.

Portions of the contents of these coverage criteria are taken directly from the U.S. Preventative Services Task Force website.

This information is for most, but not all, CoOportunity Health plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage.

CoOportunity Health has contracted with HealthPartners Administrators, Inc. to provide claims processing, medical management and certain other administrative services.