Health Maintenance Guidelines

BlueJourney HMO and BlueJourney PPO

Health Maintenance Guidelines1,2

BlueJourney HMO and BlueJourney PPO

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Services

Service Recommended Ages/Frequency

Initial Preventive Physical Examination (IPPE) 

Welcome To Medicare Preventive Visit 1


Once per lifetime, within 12 months of enrollment in a Medicare Part B program. 
View Medicare’s quick reference chart describing the IPPE in more depth

View Medicare’s quick reference chart describing all preventive services, including applicable medical codes


Annual Wellness Visit (AWV) 

Advance Care Planning (ACP) 19,20


Once per 12 month period; must begin no sooner than 12 months after above exam (IPPE) or if no IPPE then may occur in the 13th month after Part B eligibility began
Obesity Counseling

If BMI > 30, may have up to 22 visits within a 12 month period with one face-to-face or group Intensive Behavioral Therapy (IBT) counseling visit weekly for the first month followed by one counseling visit every other week for months 2-6 

If BMI > 6.6 pound weight loss is documented by end of month 6, then one additional face-to-face counseling visit every month for months 7-12 is covered  

If BMI < 6.6 pound weight loss is documented by end of month 6, a reassessment of the Member’s willingness to change and BMI is appropriate after an additional 6 month period

Medicare Diabetes Prevention Program (MDPP)20
Members with prediabetes may be eligible to begin and maintain diabetes prevention services from a MDPP participating provider
Diabetes Self Management Training (DSMT)
If diabetic, up to 10 hours of initial training within a continuous 12-month period; up to 2 hours of follow-up training for each calendar year after the initial 10 hours of training have been completed
Medical Nutrition Therapy (MNT)

If diabetic or Member with kidney disease or one who has received a kidney transplant within the last 36 months, 3 hours of one-on-one counseling with a registered dietician or nutrition professional in the first year 

2 hours of such counseling for each subsequent year

Lung Cancer Screening Counseling

One counseling/shared decision-making visit must be made prior to the first low dose chest CT scan (LDCT) 

Subsequent counseling per 12 month period as needed17

Alcohol Misuse Screening/Counseling

One screening per 12 month period 

If positive, up to a maximum of four brief face-to-face counseling sessions per 12 month period with no more than 1 session per day

Smoking/Tobacco Use Cessation Counseling
Two cessation attempts per 12 month period (each cessation attempt includes a maximum of four intermediate or intensive counseling sessions), regardless of any tobacco-related disease
Cardiovascular Disease (CVD) Counseling
One face-to-face CVD risk reduction visit per 12 month period for Intensive Behavioral Therapy (IBT) counseling
Sexually Transmitted Infections (STIs) Counseling
Two face-to-face STI prevention visits per 12 month period for High Intensity Behavioral Counseling (HIBC)


Screenings

Screenings Recommended Ages/Frequency
Depression Screening
One screening per 12 month period
One or two of: Total Serum Cholesterol 
High Density Lipoprotein (HDL) direct measurement 
Triglycerides
Once per 60 month period for Members without signs/symptoms of CV disease
Lipid panel includes the above 3 measures and is an alternative 
Once per 60 month period for Members without signs/symptoms of CV disease
Fasting Plasma Glucose and/or Post-glucose Challenge Test4,20

One screening test every 6 months for pre-diabetic Members 

One screening test per 12 month period for all others at risk4 for diabetes but never tested or not diagnosed with pre-diabetes

HIV Test

One screening test per 12 month period for those younger than 15 or older than 65 at increased risk13 for infection 

For pregnant Members, up to three tests per pregnancy 

One test per 12 month period for those between 15 and 65 without regard to perceived risk

Hepatitis B Test
One time screening test for asymptomatic non-pregnant adolescent and adult Members at high risk18 for hepatitis B. Pregnant women should be screened at their first prenatal visit for each pregnancy and rescreened at delivery for those with new or continued risk factors.18 One repeat screening test per 12 month period for Members at continued high risk18
Hepatitis C Test

One-time screening test for Members not at high risk and born from 1945 through 1965 

Initial screening for Members at high risk with a current or past history of illicit injection drug use and also for Members who received blood transfusions before 1992 

One repeat screening test per 12 month period for Members at continued high risk16

STI Testing12

One screening test per 12 month period for men at increased risk13 for syphilis 

One screening test per 12 month period for non-pregnant women at increased risk13 for each STI -- Chlamydia, gonorrhea and syphilis 

Up to two occurrences per pregnancy of screening for Chlamydia and gonorrhea in pregnant women who are at increased risk for STIs and continued increased risk for the second screening13 

One occurrence per pregnancy of screening for syphilis in pregnant women 

Up to an additional two occurrences per pregnancy of screening for syphilis in pregnant women if the Member is at continued increased risk for STIs13 

One occurrence per pregnancy of screening for hepatitis B in pregnant women 

One additional occurrence per pregnancy of screening for hepatitis B in pregnant women who are at continued increased risk for STIs13

Digital Rectal Exam with Prostate Specific Antigen Test
Once per 12 month period for male Members age 50 and older
Clinical Breast Exam 
Pelvic Exam with Pap Smear

Once every 24 months for all female Members not at high risk 

Once every 12 months if at high risk14

Pap Smear/HPV DNA co-testing

Asymptomatic females age 30–65 

Once per 60 month period

Glaucoma Screening
One screening per 12 month period for Members at high risk5
Routine Hearing Exam15
Once per calendar year, if a covered benefit15
Abdominal Ultrasound
One-time screening for abdominal aortic aneurysm (AAA) for male Members ages 65-75 who have smoked at least 100 cigarettes in their lifetime or for Members of any age/gender with a family history of AAA, a personal history of other vascular aneurysms, coronary artery disease, cerebrovascular disease, atherosclerosis, hypercholesterolemia, obesity and hypertension
Mammogram  may also include screening digital breast tomosynthesis as well as computer-aided detection

One initial baseline screening for female Members ages 35-39 

One screening per 12 month period for female Members age 40 and older

Bone Mass Measurement

One screening test every 2 years for high-risk6 Members 

More frequently if medically necessary

Fecal Occult Blood Test7
Once per 12 month period for Members age 50 and older
Flexible Sigmoidoscopy
Once per 48 month period for Members age 50 and older (unless the Member does not meet the criteria for high risk8 for colorectal cancer and the Member had a screening colonoscopy within the past 10 years)
Colonoscopy

Once per 24 month period for Members at high risk6 for colorectal cancer 

Once per 120 month period for Members not at high risk8 for colorectal cancer (unless the Member had a covered screening flexible sigmoidoscopy within the past 4 years)

Barium Enema X-ray9

Once per 24 month period for Members at high risk8 for colorectal cancer 

Once per 48 month period for Members age 50 and older not at high risk8 for colorectal cancer (unless the Member does not meet the criteria for high risk8 for colorectal cancer and the Member had a screening colonoscopy within the past 10 years)

Multi-target Stool DNA (sDNA) Test (Cologuard)
Once per 36 month period for Members ages 50-85 who have no symptoms or signs of colorectal disease and who are not at high risk8 for colorectal cancer
Low Dose Chest CT Scan (LDCT)
Once per 12 month period for Members ages 55-77 who have no signs/symptoms of lung cancer, have a tobacco smoking history of at least 30 pack-years and are current smokers or have quit smoking within the last 15 years17


Immunizations

Immunizations
Recommended Ages/Frequency
Influenza (Flu) [includes H1N1]
Once per flu season (flu season = August through March) 
Additional flu shots if medically necessary
Pneumococcal Vaccines (PCV13/PPSV23)
An initial pneumococcal vaccine to all Members who have never received a pneumococcal vaccine 
A different, second vaccine should be given one year after the first vaccine10
Hepatitis B (HBV)
One series of vaccine for Members at intermediate or high risk for hepatitis B16


1 Includes medical/social history review, depression screen, functional ability and safety screen, height, weight, BMI, blood pressure, visual acuity screen, end-of-life planning, optional screening EKG, and education, counseling, and referral for other Medicare covered preventive services as appropriate.

2 Services that need to be performed more frequently than stated due to specific health needs of the Member and that would be considered medically necessary may be eligible for coverage when submitted with the appropriate diagnosis and procedure(s) and are covered under the core medical benefit.

3 The Routine Hearing Test remains as the only intervention which is provided in excess of traditional Medicare Part B coverage (see below, footnote #13).

4 Members with one of the following are eligible: hypertension, dyslipidemia, obesity (BMI > 30), or prior diagnosis of elevated impaired fasting glucose or glucose intolerance. Members with two of the following are also eligible: overweight (BMI > 25 but < 30), family history of diabetes, age 65 years or older, or personal history of gestational diabetes or giving birth to a baby weighing > 9 pounds.

5 High-risk criteria are: a family history of glaucoma; or personal history of diabetes; or African-American age 50 and older; or Hispanic-American age 65 and older.

6 Members with any of the following are eligible: estrogen-deficient female Members at risk for osteoporosis, Members with certain spinal abnormalities evident by x-ray, Members receiving (or expected to get) long-term (more than 3 months) corticosteroid therapy, Members with primary hyperparathyroidism, or Members being monitored to assess the response to FDA-approved osteoporosis drug therapy.

7 For guaiac-based testing, six stool samples are obtained (2 samples on each of 3 consecutive stools, while on appropriate diet, collected at home). For immunoassay testing, specific manufacturer’s instructions are followed.

8 High-risk criteria are: a close relative (sibling, parent, or child) who has had colorectal cancer or an adenomatous polyp; or a family history of familial adenomatous polyposis; or a family history of hereditary nonpolyposis colorectal cancer; or a personal history of adenomatous polyps; or a personal history of colorectal cancer; or a personal history of inflammatory bowel disease, including Crohn’s Disease and ulcerative colitis.

9 Covered as an alternative to either a screening flexible sigmoidoscopy or a screening colonoscopy.

10 According to current guidelines set forth by the Centers for Disease Control and Prevention (CDC), PCV13 is intended to be the initial vaccine and PPSV23 the second vaccine. However, prior pneumococcal vaccination history should be taken into consideration, as the reverse order may sometimes be justified. Receiving multiple vaccinations of the same vaccine type is not generally recommended.

11 Capital BlueCross considers Members to be “high risk” in accordance with the guidelines set forth by the Centers for Disease Control and Prevention (CDC) 

12 Covered screenings are for Chlamydia, gonorrhea, syphilis and/or Hepatitis B. Recommendations for screening of pregnant women are too detailed for inclusion here – refer to Centers for Medicare & Medicaid Services (CMS)

13 Increased risk criteria are based upon US Preventive Services Task Force (USPSTF) guidelines and include any Medicare beneficiary who asks for the testing 

14 High-risk criteria are: women with a high risk for developing cervical or vaginal cancer or those of childbearing age with an abnormal Pap test within past 3 years.

15 This intervention is provided in excess of traditional Medicare Part B coverage but it is not a covered benefit for all BlueJourney options. [Excluded from this extra benefit are BlueJourney Essential HMO and BlueJourney Classic PPO.]

16 Continued high-risk: Members who have had continued illicit injection drug use since the prior negative screening test.

17 Initial/subsequent lung cancer screening visits and written orders for eligible LDCT scans require certain medical record elements, which are too detailed for inclusion here – refer to Centers for Medicare & Medicaid Services (CMS) 

18 High-risk is defined as persons born in countries and regions with a high prevalence of hepatitis B virus (HBV) infection (i.e., > 2%), US-born persons not vaccinated as infants whose parents were born in regions with a very high prevalence of HBV infection (i.e., > 8%), HIV-positive persons, men who have sex with men, injection drug users and household contacts or sexual partners of persons with HBV infection. Continued high-risk refers to men who have sex with men, injection drug users and household contacts or sexual partners of persons with HBV infection AND who do not receive hepatitis B vaccination.

19 ACP must be performed by the same provider on the same date as a paid AWV to be considered as a preventive service.

20 MDPP fact sheet about Member eligibility and MDPP search tool for participating providers/organizations

Reference Sources: Centers for Medicare & Medicaid Services; Novitas Solutions; Centers for Disease Control and Prevention (CDC)

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Updated November 1, 2019

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