Understanding Your Preventive Care Benefit

What is "preventive care"?

The term “preventive care” refers to health care services meant to help you avoid serious medical problems through routine care and screening.

  • Some preventive care services help identify a health issue before it becomes very serious—like your cholesterol test.
  • Some preventive care services help prevent a health issue before it happens—like your annual flu shot.

Are all preventive care services free?

No. Many services that are considered preventive in terms of your personal health do not meet the guidelines for zero-cost preventive care.

There are two factors that determine whether a preventive care service is available to you at no cost:

1. The recommended guidelines for preventive care services appropriate for your age

2. The medical information provided on your claim

The specific preventive services that are available to you at zero cost will vary throughout your lifetime based on your age.

Generally speaking, a service usually does not qualify as zero-cost preventive care if a medical problem is known, suspected, or found during the course of care.

This means that you may have to pay some of the cost of an otherwise qualified service (such as a copay, coinsurance, or deductible) based on your personal medical situation.

Here are some quick tips to help you and your provider determine when services may not be part of the preventive benefit:

  • Medical office visits or physical exams to establish a member with a new provider or to diagnose, treat, or monitor a condition or risk factor.
  • Laboratory services that are not specifically defined as preventive care within the federal recommendations for your age.
  • Services that are diagnostic or therapeutic in nature.
  • Services intended to monitor existing conditions for ongoing maintenance or surveillance of potential complications.

If you receive coverage under a retiree benefits plan, you may not have zero-cost preventive benefits available to you. Check your benefits in the Member Resource Center or contact customer service at (800) 247-2583 for more information.

I received a bill for care that I thought would be free. What happens now?

When it comes to zero-cost care, it is very important to review your benefits coverage in advance. Make sure you understand any requirements or limitations for zero-cost care before your appointment.

Once you have received care from a facility or provider, you will be responsible for any copays, coinsurance, or deductibles that apply.

What if I still don’t understand whether a care or service should be free for me?

If you have any questions about your plan coverage, benefits limitations, or the specific preventive care and screening services that are available to you or your family members, contact customer service before your scheduled care appointment. We’re here to help you!