Plan Design Best Practices

Preventive Care    Co-Pays     Diabetes Mellitus

Plan design specialists may use these tips to aid in their company's plan design. Select an area of interest from the list above.

Preventive Care

The following specific Preventive Care is covered by the Plan:

A. Females

• Exams: One physical exam every three Plan Years to age forty (40), every two Plan Years from age forty (40) to age fifty (50) and every Plan Year after age fifty (50). A colonoscopy will be limited to one at age fifty (50) and every ten years thereafter; earlier and more frequent if high risk.
• Lab and x-rays: Routine venipuncture, urinalysis, pap test, CBC, chemical screen and lipid panel. Also EKG and/or chest x-ray if deemed necessary by Physician.
• Mammograms: One before age forty (40), and one per year at age forty (40) and thereafter.
• Prenatal:
  1. 1. Schedule of Prenatal Care visits:
     • a. First through sixth months – visits once per month.
       b. Seventh and eighth months – visits every two weeks.
       c. Ninth month until delivery – visits once per week.
  • 2. To be included in visit
    • a. Weight, each visit.
    • b. Blood pressure, each visit.
    • c. Fundal height (McDonald’s), each visit.
    • d. Fetal heart rated, each visit.
    • e. Check for edema, each visit.
    • f. Pelvic examination, as indicated.
    • g. Other examination, as indicated by symptoms.
    • h. Prenatal education, each visit.
    • i. Nutrition and appetite, each visit.
    • j. Family and personal adjustment, each visit.
    • k. Urinalysis for glucose and albumin, each visit.
    • l. Hematocrit and hemoglobin, at 32 to 34 weeks (more often if anemic).
    • m. Urine culture, as indicated by signs or symptoms.
    • n. Rh Titers, if initially negative, twice more during; if positive, more often as indicated by titer levels.
    • o. Other tests, as indicated by signs and symptoms.
  • 3. Visits are included in the global CPT code, laboratory charges will be considered separately.
  • 4. Usual prenatal care, in addition to regular visits listed in #2 above, include the following:
    • 4 – 8 weeks of pregnancy: initial visit
      • Pap smear and general exam
      • Blood tests: Syphilis (RPR), Hepatitis B surface antigen, Rubella tiler, blood type and Rh, RH antibody, CBC, Cystic Fibrosis screen, HIV optional.
      • For people who have had blood transfusions or used I.V. drugs: Hepatitis C tests and HIV
      • Culture vaginal canal for: Gonorrhea, Chlamydia and Group B Strep
      • Urine culture and analysis
    • 8 – 12 weeks of pregnancy:
      • Ultra sound if date and size of pregnancy is questionable – sometimes used more than once for dates
    • 14 – 21 weeks of pregnancy
      • Ultra sound to check for fetal abnormalities
    • 16 – 20 weeks of pregnancy:
      • Triple blood screen for Downs and other congenital abnormalities
    • 24 – 28 weeks
      • Glucose challenge test or other tests for Diabetes
    • 28 weeks of pregnancy:
      • Rhogam drug for Rh negative mothers who have Rh antibodies
    • 35 weeks of pregnancy:
      • Cultures for Group B Strep
    • 5. Any woman over the age thirty-five (35) is allowed one amniocentesis. If another amniocentesis is determined to be Medically Necessary, it must be pre-approved by the Plan Sponsor.
    • 6. A woman is allowed one Medically Necessary sonogram to determine any condition other than the expected delivery date. Anything more than this, which has been determined to be Medically Necessary, must be pre-approved by the Plan Sponsor.
    • 7. Any treatment beyond those treatments listed above and required due to emergency complications must be approved by the Plan Sponsor within forty-eight (48) hours of the occurrence.

NOTE: The Prenatal Care Benefit does not apply in the case of pregnancy of a Dependent child.

B. Males

• Exams: One physical exam every three Plan Years to age forty (40), every two Plan Years from age forty (40) to age fifty (50) and every Plan Year after age fifty (50). A colonoscopy will be limited to one at age fifty (50) and every ten years thereafter; earlier and more frequent if high risk.

• Lab and x-rays: Routine venipuncture, urinalysis, digital rectal exam after age forty (40), Prostate Specific Antigen test, CBC, chemical screen and lipid panel. Also EKG and/or chest x-ray if deemed necessary by Physician.

C. Children from birth to age sixteen (16)

Eligible charges include history, physical examination, development assessment, anticipatory guidance, immunizations and laboratory tests.

Co-Pays

Co-Pays are recommended for most medical eincounters as a means of sharing costs between a health plan and the health plan participant. It is important that economic discipline be incorporated into all health desicion making. Common co-pay structures among ECOH member employers are $10.00 to $20.00 for physician office visits and 20% to 30% fo inpatient or outpatient services.

For non-grandfathered plans with plan years beginning on or after September 23,2010, preventative services must be covered with no cost sharing. The services to be covered without co-pay include:

• For all plan participants, United States Preventative Services Task Force (USPSTF) recommendations that have a current rating of A or B.  United States Preventative Services Task Force
• For children, adolescents, and adults, Centers for Disease Control and Prevention (CDC) approved immunizations recommended for routine use by its Advisory Committee on Immunization Practices. Centers for Disease Control and Prevention
• For infants, children, and adolescents, Health Resources and Services Administration (HRSA) guidelines for preventative care and screenings. Health Resources and Services Administration
  
  
• Diabetes Mellitus
  
  Diabetes Mellitus management is a major quality initiative of the Coalition. Members are strongly encouraged to include the following coverage within their plan designs:

• Four (4) visits during the first year for dietetic and diabetic education of new diabetics
• One (1) visit per year thereafter for education
• Cover Glucometer test strips and syringes
• One (1) eye exam per year (dilated) by ophthalmologist
• Ask for the ECOH Diabetic Self-guide Booklet from your doctor.

Infertility Services Not Covered
Sample SPD Language

Infertility services including infertility drugs, surgical or medical treatment programs for infertility, including in vitro fertilization, gamete intrafallopian transfer (GIFT), zygote intrafallopian transfer (ZIFT), variations of these procedures, and any costs associated with the collection, washing, preparation or storage of sperm for artificial insemination (including donor fees). Cryopreservation of donor sperm and eggs is also excluded from coverage.

Bariatic Services Not Covered
Sample SPD Language

Medical and surgical services intended primarily for the treatment or control of obesity which are not medically necessary. Excluded services include, but are not limited to, weight reduction procedures designed to restrict your ability to assimilate food, such as gastric bypass, gastric balloons, jaw wiring, stomach stapling and jejunal bypass.