Preventive care

All three medical options — PPO, EPO, and HDHP — provide preventive care benefits for you and your enrolled family members. There is no cost to you when using network providers for the following:

• yearly well visits with your primary care physician*
  
• annual well-woman visits with your gynecologist* 
  
• wellness exams for children
• health screenings and immunizations listed on the Preventive Schedule 
• additional specified screenings and immunizations for internationally adopted children up to age 18 

For a service to be considered preventive, you must go to the doctor without signs or symptoms of illness for the annual exams, tests, and immunizations specified by the plan for your age and gender.

*Visits do not need to be 12 months apart and may be scheduled anytime between Jan. 1 and Dec. 31 each calendar year.

Note: Retired members with medical coverage through the Board of Pensions and those enrolled in Triple-S or GeoBlue also have preventive care benefits under their plans, but coverage details may differ. Consult your plan’s provisions for details.

Preparing for your well visit

Make the most of your well visit. Before you go, do the following:

• Confirm that your doctor is a network provider by:
  
• calling Quantum Health at 855-497-1237
  
• using the Care Finder tool on the Quantum Health website, or
• contacting your doctor’s office
  
• Review the Preventive Schedule to see which screenings and immunizations you qualify for based on your age and gender.
• Make a list of any questions you have and bring them with you to your appointment.

If the doctor diagnoses a condition

Your well visit is covered under the preventive care benefit even if your doctor diagnoses a health condition during your exam. For any subsequent care related to that health condition or for tests that are not listed on the Preventive Schedule, you must pay the applicable copay, deductibles, and/or 20% coinsurance.

If you think a claim for a preventive service was processed incorrectly, call your provider. If you need more assistance, call Quantum Health at 855-497-1237.

Coverage of additional services

The Board follows the recommendations of the U.S. Preventive Services Task Force. If a provider conducts tests or services beyond those recommendations, they are considered outside the scope of the preventive care benefit and subject to regular plan provisions (i.e., deductibles, copays, and/or coinsurance). For example, some providers perform routine electrocardiograms (EKGs) during preventive exams; coverage for this test would be subject to regular plan provisions.

Out-of-network reimbursement (PPO only)

If you’re enrolled in the PPO and see an out-of-network provider for preventive care, the plan pays 50% of the plan allowance for office visits, with no deductible, and you pay the remaining 50%, plus any charges above the allowed amounts. To find network providers, call Quantum Health at 855-497-1237 or log on to the Quantum Health website and use the Care Finder tool.

Note: The EPO and HDHP do not cover preventive care services received from out-of-network providers.

Preventive health recommendations for internationally adopted children

If you are enrolled in the PPO, EPO, or HDHP, you can take advantage of a benefit designed to meet the unique health needs of children adopted from other countries. This benefit is available for children through age 18 and includes the following:

• Overseas medical exam to detect contagious diseases that could affect their eligibility to obtain a visa.
• Exams and certain health screenings, such as hepatitis screenings, HIV ELISA, stool examination for ova and parasites, skin testing for tuberculosis, and G6PD deficiency screening, in the United States. Children adopted from other countries should have a thorough exam by a pediatrician within one to two weeks of their arrival. After initial screening, children may need to be retested for some diseases.
• Other recommended screenings, including hearing, vision, and developmental screenings as well as a dental evaluation for children ages 18 months and older.