Preventive care

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Q&A: 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.
green icon of a syringe View annual flu vaccination details.

Please note that not all screening tests are covered at no cost to you—it is only those that doctors and scientists have determined to be of the greatest value in keeping you healthy. Examples of tests that will lead to some cost-sharing are screening metabolic panels or a screening EKG.

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.

green icon of a list  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.


green icon of a telephone   Learn about expanded telehealth services.


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

Preventive benefits

With a network provider, covered at $0

During an annual preventive office visit, you'll receive services such as:

1. Annual cholesterol screening
2. Depression screening
3. Healthy habit counseling
Age and frequency recommendations vary, but benefits cover one mammogram annually
Age and frequency varies. May include a pap smear with HPV co-testing.
Age and frequency varies
Doses and age-specific vaccines vary
Age and frequency varies
Annual sexually transmitted infection (STI) screening and counseling for adults and adolescents

Non-preventive services

Some costs may apply

If other health problems are present and addressed at your annual preventive office visit (e.g a sore throat), you may be billed for an office visit.

Some costs may apply to visits that address chronic or pre-existing conditions, such as diabetes, heart problems, arthritis, depression, asthma or other chronic lung conditions, or mental health.
Testing if a breast lump is found or a follow-up test if screen is abnormal
Follow-up visits if cervical cancer cells are found
Additional colonoscopies if polyps or cancer are found
Vaccines for travel outside the U.S.
Medications to treat an infection
Medications to treat an infection (e.g. chlamydia)