The Department of Health and Human Services requires most benefit plans to include certain preventive care services to be covered without any out-of-pocket costs as long as participating care provider provides the service.
We update our Coverage Determination Guideline (CDG) for Preventive Care Services to help you identify and correctly code preventive services. View our Medical & Drug Policies and Coverage Determination Guidelines.
We update the CDG when we receive new guidance about preventative services and revised codes. The United States Preventive Services Task Force is one of the primary references driving changes to the CDG. We must cover items that have an “A” or “B” rating without cost-share by non-grandfathered benefit plans. This applies to both fully insured and self-funded benefit plans. While grandfathered benefit plans are not required to implement these changes, some grandfathered benefit plans have chosen to cover preventive care services at no cost-share.
This does not apply to members enrolled in government health benefit plans (Medicare/Medicaid) including our Medicare Advantage benefit plans. For information on Medicare coverage of preventive services, view Medicare Advantage Coverage Summaries > Preventive Health Services and Procedures.
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