What is Preventive Care?

Preventive care helps detect or prevent serious diseases and medical problems before they can become major. Annual check-ups, immunizations, and flu shots, as well as certain tests and screenings, are a few examples of preventive care. This may also be called routine care.

What’s the difference between preventive care and diagnostic care?

Diagnostic care is related to services in which your provider is looking for something specific, often based on the results of a preventive test or screening. For example, a radiologist may ask for 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:

• Annual check-up (1 per calendar year): This is when your Primary Care Provider (PCP) checks all areas of your health—physical, as well as emotional. This can help detect any health concerns early, before they become major medical problems.
• Flu shot (1 per year): This is typically covered 100% under most health plans and helps protect you from certain strains of the flu virus.
• Mammogram (1 per calendar year, usually after the age of 40): Routine X-rays of breast tissue to check for any signs of cancer or other abnormalities. Some health plans may also cover costs for 3D imaging.
• Colonoscopy (typically 1 per every 10 years, usually after the age of 50): Screening for colon cancer.
• Vaccinations (usually administered during childhood, includes boosters as needed): Vaccinations like measles, mumps, rubella, polio, etc. are covered 100%.

Examples of non-preventive care include:

• Diagnostic tests and screenings: These are not routine tests and screenings. For example, if your radiologist finds something on your mammogram and wants another, it’s considered a diagnostic mammogram and will typically not be covered as preventive care.
• Additional primary care visits: Most health plans will cover you for 1 annual check-up with your doctor. Other visits during the same calendar year will likely not be covered as preventive. For example, let’s say you have flu symptoms and need to see your doctor—that’s not a covered preventive care visit.
• Specialist visits: Visits to a specialist (gastroenterologist, orthopedist, neurologist, podiatrist, etc.) for a particular 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 many do not.

Is preventive care free?

Most health plans are required by law to cover eligible preventive care services at 100%. This includes health insurance plans you get through your employer as well as those you may buy 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 stay as healthy as possible. Regularly scheduled visits and tests allow your doctor to identify any medical problems 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 helps your doctor provide proactive care and treatment
• Routine care can help you stay focused on your own health goals

How do you know what preventive care you need and when?

Your PCP can help you coordinate what tests and shots are right for you. They may consider things like family history, age, sex, current health status, and more.

See a complete list of preventive care services

Preventive care is often covered 100% by your health plan and offers many benefits, both in cost and health. If you have questions about what’s covered and not covered, or when you should have certain tests done, make sure to ask your doctor.