According to the CDC, cancer is the second leading cause of death in the U.S. Between 30% and 50% of cancer cases are preventable. We cover a variety of preventive services, including cancer screenings, at no cost (no copay and no deductible) to our members. Preventive screening services can help detect cancers in early stages, when treatment is more likely to be successful.
Screening coverage for commercial members
- Breast cancer prevention counseling (for those at high risk) and screening mammogram (ages 40+ or at high risk)
- Cervical cancer screening (Pap smear test) (ages 21+)
- Colorectal cancer screening (ages 45+)
- Lung cancer (ages 50-80 with history of smoking)
- Skin cancer counseling (ages 6 months-24 years for those with fair skin type)
Preventive vs. diagnostic care
When scheduling appointments, please remind your patients that during the preventive care visit, if diagnostic care is needed to treat a new symptom or an existing problem, cost share (e.g., copay, coinsurance or deductible) amounts may apply for these additional services.
Earn incentives for preventive care visits
By opting in to participate in our Quality Incentive Program, you can earn incentives for completing breast cancer screenings, cervical cancer screenings and colorectal cancer screenings for your Individual on-exchange patients.
View our preventive care lists
View the complete list of preventive services that we cover in English and Spanish, listed for members of all ages, pregnant members and children.
Member reminders for colorectal cancer, breast cancer and cervical cancer
Eligible members may receive opt-in texts asking whether they would like to receive preventive screening reminders. If the member agrees, they receive a text message emphasizing the importance of the screening and letting them know they might be due and should make an appointment. The member can respond to the text to request help scheduling their appointment. The member’s request triggers a call from a BridgeSpan care advocate to help the member find a provider or schedule an appointment.
Best practices and member flyers
Our Quality Improvement Toolkit includes best practices and resources you can share with your patients that address the importance of breast, cervical and colorectal cancer screenings.
Claims submission
Learn more about preventive services modifiers and codes.
Many factors influence members’ experience with obtaining medications and adhering to their treatment plan. We are increasing the support and assistance we offer for members to improve their health outcomes and experience.
Reasons your patient may not be taking medications you prescribed
Sometimes members are prescribed medications they cannot obtain for various reasons (e.g., cost, nonformulary, pre-authorization or step therapy requirements or medications excluded from coverage). These barriers can lead to untreated or poorly controlled conditions and impact the quality of care the patient feels they received.
Look for the Medications and member experience with medications category in the Quality Improvement Toolkit. The toolkit includes best practices and action items, along with a variety of flyers you can share with your patients.
As a health care provider, you know that medical care alone doesn't determine a patient’s health outcome. The environments where people live, learn, work and play have a profound impact on their well-being. These factors, known as social determinants of health (SDoH), are crucial pieces of the health care puzzle. Understanding and addressing SDoH leads to better outcomes and helps close critical health equity gaps in our communities.
SDoH ICD-10-CM Z
The SDoH ICD-10-CM Z codes make it possible to measure social risk factors and social needs. They add greater specificity to capture a more holistic view of a patient’s health. Implementing SDoH in your practice documentation through ICD-10-CM Z codes is essential for:
- Creating comprehensive patient care plans
- Identifying community resource needs
- Supporting population health initiatives
- Improving health equity
Best practices
- Screen patients using standardized SDoH assessment tools
- Document findings using appropriate Z codes
- Connect patients with community resources
- Follow up on referrals and support services
Provider resources
Our Health Equity Toolkit includes resources for you to learn more about health disparities, and to develop and improve your cultural competency and health literacy best practices as you and your staff provide care for our members.
Patient resources
- 211.org for community support services
- FindHelp.org for local resources
- Customer service support by calling the number on the back of their member ID card
Every health care journey deserves a roadmap. National Healthcare Decisions Day, April 16, 2024, empowers providers and patients to create that map together through meaningful conversations about future care preferences.
Why It matters
Advance care planning (ACP) isn't just about end-of-life decisions —it's about ensuring your patients' voices are heard at every stage of their health care journey. These vital conversations help align medical care with personal values and wishes, providing peace of mind for patients and their families.
Getting reimbursed for these important conversations
We support these crucial discussions by reimbursing for ACP conversations with members, regardless of age or health status.
Key elements of ACP discussions
- Helping patients choose a trusted medical decision-maker
- Exploring current health status and future possibilities
- Understanding personal values and beliefs that shape care decisions
- Creating or updating essential documents (health care representative, advance directives, POLST/MOLST forms)
Tools for success
Access these valuable resources to enhance your ACP discussions:
Learn more
Our Personalized Care Support Program is a comprehensive set of benefits and supports available to members living with serious illness and their caregivers. Our vision is that every person living with serious illness will experience personalized care that is consistent with their values, goals and preference; and caregivers will feel included, honored and supported.
Tobacco use is the leading cause of preventable disease, disability and death in the U.S. We measure the rate at which our members are advised to quit smoking. Currently, our score for this CAHPS/HOS measure is lower than national benchmarks, indicating that this is an area of opportunity for us. Providers play a key role in helping patients decrease tobacco use by introducing and encouraging the use of tobacco cessation tools and resources.
Integrating treatment into your routine clinical workflow and engaging the entire health care team in treatment delivery can make a difference.
Quality Improvement Toolkit
Our Quality Improvement Toolkit includes information about best practices and action items to help you support your patients, including:
- Advising patients to quit using tobacco products
- Offering treatment options, such as counseling and/or medication
- Referring to community resources, such as support groups
- Following up and assessing progress overtime
In addition, the toolkit includes Healthwise Knowledgebase flyers in English and Spanish for you to share with your patients.
In the toolkit, select Tobacco cessation from the Categories dropdown list.
The CDC’s Smoking and Tobacco Use hub
The CDC has information for health care providers, including guidance for care settings, clinical tools and cessation support materials to give to patients.