Preventive care

Preventive care is provided at visits that are usually with your primary care provider (PCP). Routine screenings, shots (vaccinations), and counseling to prevent illness, disease or other health problems are a few examples of preventive care.

Diagnostic care refers to services provided as a result of symptoms or problems you have, previously identified diagnoses or problems, or after the results of a preventive test or screening are reviewed. The follow-up care is diagnostic and not covered as preventive care.

Diagnostic and follow-up care may have out-of-pocket costs (copays, deductibles, cost-sharing).

Chronic care refers to services provided to help you manage chronic illnesses, such as diabetes, asthma, high blood pressure, or high cholesterol. This care is also not covered the same way as preventive care, and will usually have out-of-pocket costs like diagnostic care does.

If you and your provider discuss any of your chronic illnesses at your annual preventive visit, you may have out-of-pocket costs.

Annual visits with your PCP, vaccinations (like the flu shot) and certain routine tests and screenings are examples of preventive care.

These preventive services, and more, are covered at no ($0) out-of-pocket costs to you when received by an in-network provider*:

• Annual preventive visit (1 per year, more visits for children and adolescents): At this visit, your PCP checks all areas of your health – physical and emotional. Having an annual visit can help find early signs of health concerns before they become major medical issues.
• Mammogram (1 per year, starting at age 40): Screening X-rays of breast tissue to check for any signs of cancer or other abnormalities.
• Colorectal (colon) cancer screening (starting at age 45): Five types of tests can be used to screen for colon cancer. Talk with your PCP about which is right for you. Visit cancer.gov to learn more about each screening type.
• Vaccinations (ages and frequency vary): Routine vaccines can prevent diseases such as HPV, chickenpox, shingles, tetanus, measles, mumps, rubella, polio and whooping cough.
• Flu shot (1 per year, beginning at age 3): Annual flu shots help protect you from certain strains of the flu virus.

Non-preventive care is any care in which symptoms are present, or when treatment of an illness or management of other medical conditions is needed. This may include care for some medical conditions when a cure may be possible.
These services will have out-of-pocket costs (copays, deductibles, cost-sharing):
 

• Existing health concern or chronic medical condition services received at an annual preventive visit: For example, treating asthma, a rash or a sore throat during your annual preventive visit.
• Diagnostic tests that result from screenings: For example, if your provider needs to see additional images after your screening mammogram, the follow-up mammogram is considered diagnostic and will include cost share.
• Additional primary care visits: One annual preventive visit with your PCP is covered (more visits for children and adolescents are covered). Other visits during the same calendar year will not be covered as preventive. For example, if you have flu symptoms and need to see your PCP—that’s not a covered preventive visit.
• Specialist visits and alternative therapies: Visits to a specialist (gastroenterologist, orthopedist, neurologist, podiatrist, etc.) for a particular problem are not covered as preventive care. Services such as chiropractic, massage, acupuncture, and other alternative health services are usually not covered as preventive care.

Preventive care is meant to help you stay as healthy as possible. Annual preventive visits, tests and screenings allow your PCP to find, treat or prevent medical problems or diseases before they become major health concerns.

Talk with your PCP about which preventive care services you need and when you need them. Your PCP will consider things like family history, age, sex and current health status. Your PCP can also help coordinate any lab tests, screenings and vaccines you are due for.

  See a list of covered preventive services from healthcare.gov.

Telehealth may be used for annual preventive visits or other appointments if no labs, screenings or vaccines are needed. Talk with your PCP if you are interested in a telehealth appointment.

*If your plan uses a provider network, review your summary of benefits and coverage for network provider details.