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Preventive Services and the Affordable Care Act

Under the Affordable Care Act and as part of Your Essential Health Benefits, Molina will cover the following government-recommended preventive services, without You paying any Cost Sharing:

 Those evidenced-based items or services that have in effect a rating of “A” or “B” in the current

recommendations of the United States Preventive Services Task Force (USPSTF) with respect to the individual involved;

 Those immunizations for routine use in children, adolescents, and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC) with respect to the individual involved;

 With respect to infants, children, and adolescents, such evidence-informed preventive care and screenings provided for in the comprehensive guidelines supported by the Health Resources and Services Administration (HRSA); and

 With respect to women, those evidence-informed preventive care and screening provided for in comprehensive guidelines supported by HRSA, to the extent not already included in certain recommendations of the USPSTF.

All preventive care must be furnished by a Participating Provider to be covered under this Agreement.

As new recommendations and guidelines for preventive care are published by the government sources identified above, they will become covered under this Agreement for product years which begin one year after the date the recommendation or guideline is issued or on such other date as required by the Affordable Care Act.

If an existing or new government recommendation or guideline does not specify the frequency, method, treatment, or setting for the provision of a preventive service, then Molina may impose reasonable coverage limits on such preventive care as long as they are consistent with the Affordable Care Act and applicable Texas law. These coverage limitations also are applicable to the preventive care benefits listed below.

To help You understand and access Your benefits, preventive services for adults and children which are covered under this EOC are listed below.

Preventive Care for Children and Adolescents

The following preventive care services are covered and recommended for all children and adolescents (through age 18), without You paying any Cost Sharing if furnished by a Participating Provider:

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Complete health history

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Physical exam including growth assessment

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Nutritional health assessment

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Vision screening

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Dental screening

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Speech and hearing screening

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Immunizations*

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Laboratory tests, including tests for anemia, diabetes, cholesterol and urinary tract infections

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Tuberculosis (TB) screening

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Sickle cell trait screening, when appropriate

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Health education

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Meeting with the parent, guardian or emancipated minor to talk about the meaning of the exam

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Lead blood level testing. Parents or legal guardians of Members ages six months to 72 months are entitled to receive from their PCP; oral or written anticipatory guidance on lead exposure, This includes how children can be harmed by exposure to lead, especially lead-based paint. When Your PCP does a blood lead-screening test it is very important to follow-up and get the blood test results. Contact Your PCP for additional questions.

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All comprehensive perinatal services are covered. This includes: perinatal and postpartum care, health

education, nutrition assessment and psychological services.

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Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) Services. Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) services, including those provided for in the comprehensive guidelines supported by the federal Health Resources and Services Administration, are covered for Members under the age of 21, including those with special health care needs.

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Depression screening: adolescents

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Hemoglobinopathies screening: newborns

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Hypothyroidism screening: newborns

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Iron supplementation in children, when prescribed by a Participating Provider

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Obesity screening and counseling: children

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Phenylketonuria (PKU) screening: newborns

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Gonorrhea prophylactic medication: newborns

*If You take Your child to Your local health department or the school has given Your child any shot(s), make sure to give a copy of the updated shot record (immunization card) to Your child’s PCP.

Preventive Care for Adults and Seniors

The following outpatient preventive care services are covered and recommended for all adults, including seniors, without You paying any Cost Sharing if furnished by a Participating Provider:

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Medical history and physical exam

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Blood pressure check

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Cholesterol check

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Breast exam for women (based on Your age)

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Mammogram for women (based on Your age)

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Pap smear for women (based on Your age) and health status including human papilloma virus

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(HPV) screening test

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Prostate specific antigen testing

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Tuberculosis (TB) screening

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Colorectal cancer screening (based on Your age or increased medical risk)

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Cancer screening

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Osteoporosis screening for women (based on Your age)

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Immunizations

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Laboratory tests for diagnosis and treatment (including diabetes and STD’s)

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Health education

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Scheduled prenatal care exams and first postpartum follow-up consultation and exam

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Bacteriuria screening: pregnant women

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Folic acid supplementation

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Breast Cancer preventive medications

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Dental care prevention including oral fluoride supplementation

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Falls prevention including exercise or physical therapy and vitamin D

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Hepatitis B screening: pregnant women

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Hepatitis B screening for adults

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Hepatitis C screening for adults

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Breastfeeding support, supplies counseling

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Rh incompatibility screening: first pregnancy visit

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Rh incompatibility screening: 24-28 weeks gestation

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Screening for gestational diabetes

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Hearing exams and screenings

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Eye exams and preventive vision screenings

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Abdominal aortic aneurysm screening: men

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Alcohol misuse counseling

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Anemia screening: women

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Aspirin to prevent cardiovascular disease (when prescribed by a Participating Provider)

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BRCA counseling about breast cancer preventive medication

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Chlamydial infection screening: women

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Depression screening: adults

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Healthy diet counseling

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Obesity screening and counseling: adults

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STDs and HIV screening and counseling

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Tobacco use counseling and interventions

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Well-woman visits

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Screening and counseling for interpersonal and domestic violence: women

Preventive Care for Adults and Seniors includes a health risk assessment at least once every three years and, for women, an annual well-woman examination.

PHYSICIAN SERVICES

We cover the following outpatient physician services:

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Prevention, diagnosis, and treatment of illness or injury

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Visits to the doctor’s office

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Routine pediatric and adult health exams

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Specialist consultations when referred by Your PCP (for example, a heart doctor or cancer doctor)

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Clinical diagnoses of Alzheimer’s Disease can be made by a Participating Provider that is a physician licensed in Texas.

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Injections, allergy tests and treatments when provided or referred by Your PCP

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Medical screening for atherosclerosis and abnormal artery structure, once every 5 years performed by a certified laboratory, and including either CT scanning measuring coronary artery calcification or ultrasonography

measuring carotid intima-media thickness and plaque. This screening is available for men who are 45 years of age or older and women who are 55 years of age or older; the Member must be either diabetic or have a high risk of developing coronary heart disease

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Physician care in or out of the hospital

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Consultations and well-child care, including necessary diagnostic follow-up care related to screening tests

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If You are a female Member, You may also choose to see an obstetrician/gynecologist (OB/GYN) who is a

Participating Provider for routine examinations and prenatal care without a referral or Prior Authorization.

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Outpatient maternity care, including Medically Necessary supplies for a home birth; services for complications

of pregnancy, including fetal distress, gestational diabetes and toxemia; services of Other Practitioners, including a certified nurse midwife; and related laboratory services

HABILITATIVE SERVICES

We cover 35 visits per year for habilitative services, which are defined as health care services and devices that are designed to assist individuals acquiring, retaining or improving self-help, socialization, and adaptive skills and functioning necessary for performing routine activities of daily life successfully in their home and community based settings. These services may include physical therapy, occupational therapy, speech therapy, and durable medical equipment.

REHABILITATIVE SERVICES

We cover Medically Necessary rehabilitative services. These services help injured or disabled Members resume activities of daily living. This means services such as physical therapy, speech therapy and occupational therapy. These would occur in the right setting for the level of disability or injury. Medically Necessary covered

rehabilitative services will not be denied, limited, or terminated if the therapy or service meets or exceeds Your treatment goals. This benefit includes up to 35 visits per year with a chiropractor. The chiropractor must provide services in connection with outpatient rehabilitation, occupational therapy and physical therapy.

OUTPATIENT MENTAL AND BEHAVIORAL HEALTH SERVICES

We cover the following outpatient care when provided by Participating Providers who are physicians or other licensed health care professionals acting within the scope of their license:

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Individual and group mental health evaluation and treatment

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Psychological testing when necessary to evaluate a Mental Disorder

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Outpatient services for monitoring drug therapy

We cover outpatient mental and behavioral health services only when the services are for the diagnosis or treatment of Mental Disorders. A “Mental Disorder” is a mental health condition identified as a “mental disorder” in the Diagnostic and Statistical Manual of Mental Disorders, current Edition, Text Revision (DSM) that results in clinically significant distress or impairment of mental, emotional, or behavioral functioning. We do not cover services for conditions that the DSM identifies as something other than a “mental disorder.”

“Mental Disorders” include the following conditions:

 Serious Mental Illness of a person of any age. “Serious Mental Illness” means the following mental disorders: schizophrenia, schizoaffective disorder, bipolar disorder (manic-depressive illness), major depressive disorders, panic disorder, obsessive-compulsive disorder, anorexia nervosa, or bulimia nervosa.

Molina Healthcare covers the screening, diagnosis and treatment of Autism Spectrum Disorder only as provided in this Agreement under (1) “Preventive Care for Children and Adolescents” in the “Preventive Services and the Affordable Care Act” section above, and (2) the “Outpatient Autism Spectrum Disorder Services” section below. OUTPATIENT AUTISM SPECTRUM DISORDER SERVICES

We cover treatment and services to Members under the age of 10 for all generally recognized services prescribed in relation to autism spectrum disorder by the Member’s PCP in the treatment plan recommended by that physician. These services include, but are not limited to:

 evaluation and assessment services;

 screening at ages 18 months and 24 months;

 applied behavior analysis as defined in Texas insurance regulations;

 behavior training and behavior management;

 speech therapy;

 physical therapy; or

 medications or nutritional supplements used to address symptoms of autism spectrum disorder. The services must be provided by a Participating Provider or Other Practitioner who is licensed, certified or

registered by an appropriate agency of Texas. Their professional credentials must be recognized and accepted by an appropriate agency of the United States, or certified as a provider under the TRICARE military health system. All Covered Services are subject to the Cost Sharing requirements for Outpatient Professional Services.

After the Member reaches age ten, the Benefits and Coverage as otherwise available under this Agreement will be available to the Member. All provisions of this Agreement will apply including, but not limited to, defined terms, limitations and exclusions, Prior Authorization and any applicable benefit maximums.

OUTPATIENT SUBSTANCE ABUSE/CHEMICAL DEPENDENCY SERVICES

We cover the following outpatient care for treatment of substance abuse/chemical dependency:

 Day-treatment programs

 Intensive outpatient programs

 Individual and group substance abuse counseling

 Medical treatment for withdrawal symptoms

 Individual substance abuse evaluation and treatment

 Group substance abuse treatment

We cover substance abuse/chemical dependency under this policy. We do not cover services for alcoholism, drug abuse, or drug addiction except as otherwise described in this “Outpatient Substance Abuse/Chemical Dependency Services” section.

DENTAL AND ORTHODONTIC SERVICES

We do not cover most dental and orthodontic services, but We do cover some dental and orthodontic services as described in this “Dental and Orthodontic Services” section for all Members.

Dental Services for Radiation Treatment

We cover dental evaluation, X-rays, fluoride treatment, and extractions necessary to prepare Your jaw for treatment. This includes radiation therapy of cancer or neoplastic disease in Your head or neck. A Participating Provider physician must provide the services. Molina Healthcare may authorize a Referral to a dentist.

Dental Trauma

We cover services provided to correct damage to healthy, unrestored natural teeth and supportive tissues. These services will correct damage caused solely by external, violent accidental injury. Services are limited to treatment provided within 24 months of the initial treatment. An injury as the result of biting or chewing shall not be considered to be an accidental injury.

Dental Anesthesia

For dental procedures, We cover general anesthesia and the Participating Provider facility's services associated with the anesthesia. All of the following must be true:

 You are under age 7, or You are developmentally disabled, or Your health is compromised

 The dental procedure must be provided in a hospital or outpatient surgery center because of clinical status or existing medical condition

 The dental procedure would not ordinarily require general anesthesia

We do not cover any other services related to the dental procedure, such as the dentist's services.

Dental and Orthodontic Services for Cleft Palate

services. You must meet all of these requirements:

 The services are an integral part of a reconstructive surgery for cleft palate. A Participating Provider provides the services. Molina Healthcare may authorize a Referral to a Non-Participating Provider who is a dentist or orthodontist.

PEDIATRIC DENTAL SERVICES

Pediatric dental services may be separately provided through a stand-alone dental plan that is certified by the Marketplace. Pediatric dental services are not covered under this product.

PEDIATRIC VISION SERVICES

We cover the following vision services for Members under the age of 19:

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Routine vision screening and eye exam every calendar year.

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Prescription glasses: frames and lenses, limited to one pair of prescription glasses once every 12 months.

 Covered frames include a limited selection of frames. Participating Providers will show the limited selection of frames available to You under this product. Frames that are not within the limited selection of frames under this product are not covered.

 Prescription Lenses: include single vision, lined bifocal, lined trifocal, lenticular lenses and polycarbonate lenses. Lenses include scratch resistant coating and UV protection.

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PrescriptionContact Lenses: limited to one pair every 12 months, in lieu of prescription lenses and frames; includes evaluation, fitting and follow-up care. Also covered if Medically Necessary, in lieu of prescription lenses and frames, for the treatment of:

 Aniridia  Aniseikonia  Anisometropia  Aphakia  Corneal disorders  Irregular astigmatism  Keratoconus  Pathological myopia  Post-traumatic disorders

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Low vision optical devices are covered including low vision services training, and instruction to maximize remaining usable vision. Follow-up care is covered when services are Medically Necessary and Prior Authorization is obtained. With Prior Authorization, coverage includes:

 one comprehensive low vision evaluation every 5 years;

 high-power spectacles, magnifiers, and telescopes as Medically Necessary; and  follow-up care – four visits in any five-year period

.

Laser corrective surgery is not covered.

Please refer to the Molina Healthcare of Texas, Inc. Summary of Benefits for limitations and Cost Sharing

TREATMENT FOR ACQUIRED BRAIN INJURY

We cover treatment for Medically Necessary services for an Acquired Brain Injury on the same basis as treatment for other physical conditions. Cognitive rehabilitation and communication therapies, neurocognitive therapy and rehabilitation neurobehavioral, neuropsychological, neurophysiological and neuropsychological testing and

treatment; neurofeedback therapy, remediation, post-acute transition and community integration services, including outpatient day treatment services, or any other post-acute treatment services are covered. Such services must be

necessary as a result of and related to an Acquired Brain Injury. Treatment for an Acquired Brain Injury may be provided at a hospital, an acute or post-acute rehabilitation hospital, an assisted living facility or any other facility at which appropriate treatment or therapies may be provided. Covered Services include reasonable expenses for periodic reevaluation of the care of a Member who has incurred an Acquired Brain Injury, has been unresponsive to treatment and becomes responsive to treatment at a later date. Treatment goals may include the maintenance of function or the prevention or slowing of deterioration.

FAMILY PLANNING

We cover family planning services to help determine the number and spacing of children. These services include all methods of birth control approved by the Federal Food and Drug Administration. As a Member, You pick a doctor who is located near You to receive the services You need. Our Primary Care Physicians and OB/GYN Specialist Physicians are available for family planning services. You can do this without having to get permission from Molina Healthcare. (Molina Healthcare pays the doctor or clinic for the family planning services You get.) Family planning services include:

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Health management and counseling to help You make informed choices and to understand birth control methods.

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Limited history and physical examination.

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Laboratory tests if medically indicated. This is to help you decide what birth control methods to use.

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Prescription birth control supplies and devices.

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Birth control pills, including Depo-Provera.

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Administration, insertion, and removal of contraceptive devices, such as intrauterine devices (IUD’s)

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Follow-up care for any problems You may have using birth control methods issued by the family planning

providers.

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Emergency birth control supplies when filled by a contracting pharmacist, or by a non-contracted provider, in the event of an Emergency.

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Voluntary sterilization services, including tubal ligation (for females) and vasectomies (for males).

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Pregnancy testing and counseling.

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Diagnosis and treatments of sexually transmitted diseases (STDs) if medically indicated.

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Screening, testing and counseling of at-risk individuals for HIV. Referral for treatment. PREGNANCY TERMINATIONS

Molina Healthcare covers pregnancy termination services. There are certain coverage restrictions required by the Affordable Care Act and by any applicable laws in the State of Texas.

Pregnancy termination services are office-based procedures. They do not require Prior Authorization.

If pregnancy termination services will be provided in an inpatient setting or outpatient hospital Prior Authorization is required.

Office Visit and Outpatient Surgery Cost Sharing will apply.

Keep in mind that some hospitals and providers may not provide pregnancy termination services. COVERAGE FOR CERTAIN AMINO-ACID BASED ELEMENTAL FORMULAS

We cover Medically Necessary amino acid-based elemental formulas. This is regardless of the formula delivery system. They must be used for the diagnosis and treatment of:

1) immunoglobin E and non-immunoglobin E mediated allergies to multiple food proteins; 2) severe food protein-induced enterocolitis syndrome;

3) eosinophilic disorders, as evidenced by the results of a biopsy; and

4) impaired absorption of nutrients caused by disorders affecting the absorptive surface, functional length and motility of the gastrointestinal tract.

The coverage includes any Medically Necessary services associated with the administration of the formula. It is subject to the written order of a Participating Provider. It must be for the treatment of a Member who is diagnosed with one of the above listed conditions. Coverage for formulas and special food products is provided on the same basis as any other prescription medication under this plan.

PHENYLKETONURIA (PKU)

We cover testing and treatment of phenylketonuria (PKU). This includes Medically Necessary services associated with the administration of formulas and special food products. The regimen must be prescribed by a physician and managed by a licensed health care professional in consultation with a physician who specializes in the treatment of

In document Asociación entre el clima organizacional y la calidad de atención en los servicios de salud del Hospital Rural de Picota periodo junio 2011 a mayo 2012 (página 40-44)