Typically, a physical exam is an annual checkup your physician uses to assess your overall health. Your physical exam benefits will cover this checkup and any vision, hearing, or other recommended screening tests appropriate for your age and gender. Typically, HMSA’s HMO plans, which emphasize screening and prevention, have a physical exam benefit, while most HMSA PPO plans don’t. Please review your Guide to Benefits to determine if physical exams are a benefit of your plan.
When a physical exam is required by an employer, school, or other organization
Physical exams are sometimes required for employment, school, participation in a sporting activity or other program, or for life insurance, etc. Physical exams and any associated screening procedures that are done for such reasons aren’t covered. If you receive an annual physical exam that’s covered by your plan, however, that exam can also be used to satisfy a requirement for the reasons mentioned previously.
Even if your plan doesn’t have a physical exam benefit, other plan benefits are available to ensure you have the proper screenings, assessments, and preventive services. Please review your Guide to Benefits under Special Benefits for Women, Men, Children, and Disease Management. Here are a few specific benefits that may be of interest to you if you aren’t eligible for a physical exam:
Although most HMSA PPO plans don’t cover physical exams, they do cover well-woman visits. At a well-woman visit, the member sees her ob-gyn for an annual pelvic exam, and a clinical breast exam. This visit is an important preventive service for women and is covered once per calendar year.
At a well-child visit, a pediatrician or primary care provider (PCP) performs a physical exam, hearing and vision screening, developmental/behavioral assessment, preventive guidance, lab tests, and administers immunizations for your child. If your plan is covered under the new Affordable Care Act (ACA), well-child visits aren’t subject to plan deductibles and a copayment isn’t applied if visiting an HMSA participating provider. This preventive care benefit is usually provided for children through age 21 at certain intervals if your plan is covered under the ACA. If your plan hasn’t implemented the ACA, your child may be covered for well-child visits until age 6. Please review your Guide to Benefits to determine how many well-child visits your plan allows.
If you take your child to their PCP for care other than a well-child visit (for example, an illness or injury such as the flu or a cold or sprained ankle), that visit is considered a standard physician’s office visit for which a copayment will be applied.
During the well-child visits, your child’s PCP will recommend immunizations that follow a schedule based on the guidelines set by the Advisory Committee on Immunization Practices (ACIP). These immunizations are fully covered, which means you pay no copayment. Your child’s doctor will also recommend lab tests (TB, blood tests, etc.), vision and hearing screening, and developmental/behavioral assessments based on the guidelines established by the American Academy of Pediatrics schedule, known as the Bright Futures recommendations, for preventive pediatric health care. These additional services may require a copayment or be subject to additional benefit limits if your plan isn’t an ACA plan.