What is Preventive Care?
Preventive care (sometimes called “preventative care”) is routine health care that includes screenings, services and counseling to help prevent illness, disease or other health problems.
It’s covered by your plan because it can help you stay healthy and lets you know if you may develop a health problem.
Don’t let disease sneak up on you. Preventive care could save your life.
These benefits may not apply to grandfathered members. Learn more about how to check your benefits and which members are covered.
Understanding Your Preventive Care Benefits
As mentioned in your benefits booklet, many screenings and tests are covered at 100% with no out-of-pocket costs to you as part of your health plan. Use your preventive care and stop health problems before they get serious.
Which Types of Services are Covered at 100%?
Preventive care that is 100% covered includes many important services like the ones listed below. This list is not complete, so please see the full list of preventive care services and any limitations on the Men, Women and Children pages.
- Well-baby and well-child visits
- Immunizations, like the flu shot
- Screenings and tests
- Cancer screenings, such as colon, breast, and cervical
- Blood pressure
- Cholesterol
- Diabetes
- Counseling and support
- Nutrition
- Tobacco cessation
- Alcohol misuse
- Sexually transmitted infections
Important: To be covered with no out-of-pocket costs, the service must be:
- At an in-network doctor or facility (urgent care facility, outpatient clinic or ambulatory surgery center)
- Filed by your doctor as a preventive care visit
- Identified as preventive care under the Affordable Care Act (ACA)
What Else do I Need to Know?
These services are not covered as preventive care:
Below are examples of common services your doctor may do that are considered diagnostic and not preventive care by the ACA. If your provider files them as preventive they will be denied as not covered; these services should be filed as diagnostic and will pay in accordance with your diagnostic benefit:
- Urine tests
- Hormone tests (i.e. testosterone)
- Vitamin B and D tests
- Chest X-rays
- Thyroid tests
- EKGs (electrocardiograms)
- Iron level testing
NOTE: You should feel free to ask questions about your health. However, tell your doctor that you are there for a preventive care visit and check that your question is about preventive care before talking to your doctor about any medical problem you are having.
If your question is not about preventive care, your doctor may file the visit as diagnostic (and not preventive), which may cost you money.
What is the difference between a preventive screening and a diagnostic test?
Preventive screenings are given when you are symptom free and have no reason to think you are sick. Diagnostic tests are given when you have symptoms or risk factors that indicate you may have an abnormality or problem. For example, a preventive colorectal cancer screening is a routine test that checks for cancer in people of a certain age. If your preventive colorectal cancer screening is abnormal or you have rectal bleeding, a doctor may order diagnostic tests to find out what is wrong. Preventive screenings that are listed on these pages and that are recommended by the US Preventive Services Task Force have no extra costs and diagnostic tests may have some out-of-pocket costs.
How do I avoid extra costs?
Sometimes you go to the doctor for preventive care and end up with a charge on your bill. You can avoid costs when you go to your appointment by following these steps:
- When you schedule your appointment, say that you want preventive care screenings and tests that are 100% covered by your plan.
- Ask if any tests or treatments done during your appointment might not be considered preventive care.
- Ask if talking about other health problems that are not considered preventive care during your appointment will lead to extra costs.
- Ask if lab work can be sent to a Blue Cross NC in-network lab to lower your costs.
Download a Summary of Common Screenings
The Affordable Care Act (ACA) has identified certain services as preventive care to be paid at 100%.
- These benefits are available for members of non-grandfathered individual health insurance plans.
- If you get benefits from your employer, you may also have these benefits. If your Summary of Benefits section of your Benefit Booklet contains PREVENTIVE CARE covered under federal law, then you have these benefits at no charge IN-NETWORK.
- These benefits are currently in effect unless otherwise noted.
- Check your Benefit Booklet for details on other preventive care benefits.
- This information is a reference tool and does not guarantee payment of any claims.
- For transgendered individuals, you have access to medically appropriate preventive services.
You can log in to Blue Connect to check your benefits and see your preventive care coverage.
Blue Connect