Other Preventive Services Sample Clauses
The "Other Preventive Services" clause defines the scope and inclusion of additional preventive healthcare services beyond those specifically listed elsewhere in the agreement. It typically allows for coverage or provision of services such as screenings, immunizations, or wellness visits that are recommended by recognized health authorities but not explicitly named in the contract. This clause ensures that the agreement remains flexible and up-to-date with evolving medical guidelines, thereby addressing the need for comprehensive preventive care and reducing the risk of disputes over coverage for new or updated preventive services.
Other Preventive Services. The following are required Preventive Services for all MiSalud Enrollees:
7.5.3.2.1 Vaccines (the vaccines themselves are provided and paid for by the Puerto Rico Health Department; the Contractor shall cover the administration of the vaccines);
7.5.3.2.2 Eye exam;
7.5.3.2.3 Hearing exam, including hearing screening for newborns;
7.5.3.2.4 Evaluation and nutritional screening;
7.5.3.2.5 Medically Necessary laboratory exams and diagnostic tests, appropriate to the Enrollee’s age, sex, and health condition, including, but not limited to:
7.5.3.2.5.1 Prostate and gynecological cancer screening according to accepted medical practice, including Pap smears (for Enrollees over age 18), mammograms (for Enrollees age 40 and over), and P.S.A. tests when Medically Necessary; and
7.5.3.2.5.2 Sigmoidoscopy and colonoscopy for colon cancer detection in adults 50 years and over, classified in risk groups according to accepted medical practice;
7.5.3.2.6 Nutritional, oral and physical health education;
7.5.3.2.7 Reproductive health counseling and family planning (The Contractor shall make available through its Network Providers and pay Claims for the following family planning services: counseling, pregnancy testing, diagnosis and treatment of sexually transmitted diseases, infertility assessment, and oral contraceptive medications that are used for the purpose of treating menstrual dysfunction and other hormonal conditions. Contraceptive methods prescribed for family planning purposes, however, are not covered under MiSalud, but shall be provided by the Puerto Rico Health Department);
7.5.3.2.8 Syringes for home medicine administration;
7.5.3.2.9 Annual physical exam and follow-up for diabetic patients according to the diabetic patient treatment guide and Puerto Rico Health Department protocols; and
7.5.3.2.10 Health Certificates covered under MiSalud; provided that Co-Payments applicable for necessary procedures and laboratory testing related to generating a Health Certificate will be the Enrollee’s responsibility. Such certificates shall include
Other Preventive Services. The Contractor shall provide the following Preventive Services as Covered Services for all GHP Enrollees: All immunizations shall be provided for children to age twenty-one (21), and those necessary according to age, gender, and health condition of the Enrollee, including but not limited to: influenza and pneumonia, and vaccines for children and adults with high risk conditions such as pulmonary, renal, diabetes and heart disease, among others. The Puerto Rico Department of Health shall provide and pay for vaccines to Enrollees ages zero (0) and eighteen (18), excluding those in the Commonwealth Population, through the Children’s Immunization Program. The Contractor shall cover the administration of the vaccines provided by the Puerto Rico Department of Health. The Contractor shall provide and pay for the immunizations of Enrollees in the Commonwealth Population ages zero (0) and eighteen (18), all Enrollees ages nineteen (19) to twenty (20), and those necessary according to age, gender and health condition of the Enrollee, including but not limited to influenza and pneumonia vaccines for Enrollees over sixty-five (65) years and adults with high risk conditions such as pulmonary, renal, diabetes, and heart disease, among others. The Contractor shall cover the administration of all the vaccines according to the fee schedule established by the Puerto Rico Health Department. The Contractor shall contract with immunization providers, duly certified by the Puerto Rico Department of Health, to provide immunization services. The Contractor shall administer the immunizations without any charge or deductible. Hearing exam, including hearing screening for newborns prior to their leaving the hospital nursery; Evaluation and nutritional screening; Medically Necessary laboratory exams and diagnostic tests, appropriate to the Enrollee’s age, sex, and health condition, including, but not limited to: Prostate and gynecological cancer screening according to accepted medical practice, including Pap smears (for Enrollees over age eighteen (18)), mammograms (for Enrollees age forty (40) and over), and Prostate-Specific Antigen (PSA) tests when Medically Necessary; and Sigmoidoscopy and colonoscopy for colon cancer detection in Adults age fifty (50) years and over, classified in risk groups according to accepted medical practice; Nutritional, oral, and physical health education; Reproductive health counseling and family planning. Enrollees shall be free to choose the method of...
Other Preventive Services. Colorectal Cancer Screenings Colorectal cancer screenings, such as annual fecal occult blood testing (FOBT), fecal immunochemical test (FIT), and flexible sigmoidoscopy, colonoscopy, or radiologic imaging are covered in accordance with recommendations established by the American College of Gastroenterology, after consultation with the American Cancer Society and the American College of Radiology. Colorectal cancer screenings may be may be covered more often as determined by a physician based on the Member’s medical history and/or risk factors. There may be a Cost-Share that you will be required to pay for these screenings. The Cost-Share amount depends on where the procedure is rendered and your Plan. For example, if you have a procedure performed at a physician’s office, you may be required to pay an office services Copayment, but if the service is performed on an outpatient basis, whether in a Hospital or ambulatory surgery facility, you may be required to pay an ambulatory services Cost-Share amount. Effective for Plan renewals or new Plans on or after January 1, 2012, repeat colonoscopies ordered by a physician in a benefit year will be covered without any Cost-Sharing amount, unless the Member is enrolled in one of our HSA- compatible high deductible health plans (HDHPs). Please refer to your Benefit Summary to see the Cost-Share amount you are required to pay, if any, under your Plan and to see if the benefits of this Plan are administered per calendar year or per Contract Year. Hearing Screenings Hearing screenings are covered as follows: ♥ As a part of a physical examination are only covered if a Member is under age 19. ♥ If Medically Necessary to evaluate the sudden onset of severe symptoms of an injury or illness. No coverage is available if the Member is already diagnosed with a permanent hearing loss. Immunizations Immunizations (vaccine and injection of vaccine) are covered. Coverage for vaccines such as Hepatitis is limited. The following immunizations are NOT covered: ♥ Immunizations obtained solely because they are required by a third party (such as job, travel, school, or camp). ♥ Immunizations obtained for travel. ♥ Immunizations and vaccinations for cholera, plague and yellow fever. ♥ Routine immunizations obtained at an Urgent Care Center. ♥ Vaccinations an employer is legally required to provide due to an employment risk. Newborn Care Continued coverage for a newborn child requires the newborn to be enrolled in this Plan within 61 days...
Other Preventive Services. The Contractor shall provide the following
Other Preventive Services. The Contractor shall provide the following Preventive Services as Covered Services for all GHP Enrollees:
7.5.3.2.1 All immunizations shall be provided for Pediatric Enrollees, and those necessary according to age, gender, and health condition of the Enrollee, including but not limited to: influenza and pneumonia, and vaccines for children and adults with high risk conditions such as pulmonary, renal, diabetes and heart disease, among others.