Search For:

The purpose of this bulletin is to inform providers that, as of July 1, 2022, the Department of Medical Assistance Services (DMAS) and its managed care organizations (MCOs) provide coverage for evidence-based, preventive services to all full-benefit, Medicaid adult populations in accordance with Item 304.EEEE of the 2022 Virginia Appropriations Act. The preventive services include adult wellness exams, preventive screenings and immunizations. DMAS will update its provider manuals to reflect coverage for adult preventive services as described in this bulletin.

Historical Coverage of Preventive Services for Adults

Historically, coverage for preventive services has been available to all Medicaid and Family Access to Medical Insurance Security (FAMIS) children and to Medicaid expansion adults. In addition, MCOs have offered coverage for many preventive services as enhanced benefits to adults in all eligibility categories to ensure consistency and to support overall wellness goals. The state budget that took effect July 1, 2022, establishes preventive services as standard Medicaid benefits, ensuring that all full benefit adult Medicaid members have equitable access to preventive care.

Scope of Coverage

• Coverage for preventive services through fee-for-service (FFS) and the Medicaid MCOs includes the following types of preventive services:
• Adult wellness exams
• Individual and group smoking cessation and alcohol counseling
• Vaccines, including tetanus and diphtheria, shingles, hepatitis A and B, influenza, and human papilloma virus
• Mammography, prostate and other cancer screenings
• Sexually transmitted disease screenings
• Depression screenings
• Type 2 diabetes screenings and Blood pressure and cholesterol screenings. 

The scope of coverage for preventive services aligns with the Affordable Care Act (ACA) standards, which specify that preventive care for adults be consistent with the following:

1. Services that have in effect a rating of “A” or “B” in the current recommendations of the U.S. Preventive Services Task Force (USPSTF);
2. Immunizations recommended by the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and,
3. Women’s preventive health care per current Health Resources and Services Administration (HRSA) guidelines.

The Healthcare.gov website provides a detailed list of the specific preventive services covered, per current recommendations described in subsections a-c above.

Service Authorization and Billing

Preventive services provided through either FFS or the MCOs do not require service authorization. Members do not have any patient copay obligations for these services. Providers should bill for preventive services using the most appropriate procedure codes (Current Procedural Terminology (CPT) or Healthcare Common Procedure Coding System (HCPCS)).

Member Communications

We urge providers to inform members about Medicaid coverage for adult preventive benefits, including the importance of getting regular check-ups, preventive screenings and immunizations.