What Is Preventive Care?
Preventive care helps detect or prevent serious illnesses and medical problems before they can become serious. Yearly check-ups, immunizations, and flu shots, as well as certain tests and screenings, are a few examples of preventive care. This can also be called routine care.
What's the difference between preventive care and diagnostic care?
Diagnostic care is associated with services in which your provider is looking for something specific, typically based on the results of a preventive test or screening. For example, a radiologist may request a follow-up mammogram for a patient. This follow-up is to check for something that may have been detected during the preventive or routine mammogram. The follow-up mammogram is diagnostic, and not covered as preventive care.
What are preventive care services?
Examples of preventive health services and their frequency:
- Yearly check-up (1 per calendar year): This is when your Primary Care Provider (PCP) checks all areas of your health-- physical, and psychological. This can help discover any health problems early, before they turn into major medical problems.
- Flu shot (1 per year): This is generally covered 100% under the majority of health plans and helps protect you from certain strains of the flu virus.
- Mammogram (1 per calendar year, typically after the age of 40): Routine X-rays of breast tissue to look for any signs of cancer or other irregularities. Some health plans may even cover costs for 3D imaging.
- Colonoscopy (typically 1 per every 10 years, usually after the age of 50): Screening for colon cancer.
- Vaccinations (normally administered during childhood, includes boosters as needed): Vaccinations like measles, mumps, rubella, polio, etc. are covered at 100%.
Examples of non-preventive care include:
- Diagnostic tests and screenings: These are not routine tests and screenings. For instance if your radiologist finds something on your mammogram and wants another, it's considered a diagnostic mammogram and will generally not be covered as preventive care.
- Extra primary care visits: Most health plans will cover you for 1 yearly check-up with your physician. Additional visits during the same calendar year will likely not be covered as preventive. For instance, let's say you have flu symptoms and need to see your physician-- that's not a covered preventive care visit.
- Specialist visits: Visits to a specialist (gastroenterologist, orthopedist, neurologist, podiatrist, etc.) for a specific problem are not covered as preventive care.
- Alternative therapies: Services such as chiropractic, massage, acupuncture, and other alternative health services are not considered preventive care.
- PSA blood test: This is a test to check for prostate cancer. Some health plans may cover this as preventive care, but several do not.
Is preventive care free?
The majority of health plans are required by law to cover eligible preventive care services at 100%. This includes health insurance plans you get through your employer along with those you might purchase on your own through the Health Insurance Marketplace. Your doctor must also be in-network in order to be fully covered.
What are the benefits of preventive care?
Preventive care is intended to help you remain as healthy as possible. Regularly scheduled visits and tests allow your doctor to detect any medical issues before they can become major.
Benefits of preventive care include:
- Most preventive care at no cost to you as part of your health coverage
- Early detection of medical problems, illnesses, and diseases aids your doctor provide proactive care and treatment
- Routine care can help you remain focused on your own health goals
How do you know what preventive care you need and when?
Your primary care provider can help you coordinate what tests and shots are right for you. They might consider things like family history, age, sex, current health status, and more.
Preventive care is typically covered 100% by your health plan and offers several benefits, both in cost and health. If you have questions about what's covered and not covered, or when you need to have particular tests done, be sure to ask your physician.
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