Adult Well Visits
Who is eligible
The benefit is available to all non-Medicare primary adults ages 19 and older who are covered by the State Health Plan. Adult members can take advantage of this benefit at a network provider specializing in General Practice, Family Practice, Internal Medicine and Obstetrics and Gynecology.
Standard Plan Members
The Plan will cover adult well visits beginning January 1, 2019. Adult well visits are subject to copayments, deductibles and coinsurance in covered years.
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 female visits both doctors in the same covered year, only the first well office visit received will be allowed. If you are a female ages 18-65, you can receive a routine Pap test each calendar year. In years in which Standard Plan members are not eligible for an adult well visit, the Standard Plan will cover the cost of the Pap test and the part of the office visit associated with the Pap test. You will be responsible for the remainder of the cost for the visit in those years. You can also receive an HPV test in combination with a Pap test once every five years at no member cost if you are ages 30-65.
The Plan will only cover one well visit in covered years, based on the following schedule:
Savings Plan membersYou can also take advantage of the State Health Plan’s contracted rate for an adult well visit in a non-covered year. This means eligible network providers have agreed to accept a reduced rate for an adult well visit. However, the amount you pay in a non-covered year does not apply towards your deductible or coinsurance maximum. Also, the contracted rate applies to only one well visit each year.
Beginning January 1, 2019, Savings Plan members' covered well visits will include evidence-supported services based on USPSTF A and B recommendations at an eligible network provider. The Plan will cover a well visit every year for Savings Plan members at no member cost.
Visit Peba for additional details about this benefit.
Well-child benefits, including checkups and immunizations, aim to promote good health and both early detection and prevention of illness in children enrolled in the State Health Plan. Covered children are eligible for well child care exams until they turn age 19.
- Under a year (up to six visits)
- 1 year old (up to three visits)
- 2 years old (up to two visits)
- 3 years old until he or she turns 19 years old (one visit a year).
The well-child care exam must occur after the child’s birthday.
Immunizations are one of the best ways that parents can help protect their children from serious diseases and illnesses that could be life threatening. The State Health Plan covers services specific to certain ages as recommended by the American Academy of Pediatrics for infants, children and teens. Talk to your health care provider about a schedule of immunizations to offer your child the best shot at a healthy future – at no cost to you.
Immunizations and administrative fees are covered at no cost to you. When a member receives the vaccine at an in-network provider, the vaccine and the administration fee in the doctor’s office are covered, although the office visit is not.