Preventive Care

Abdominal Aortic Aneurysm - One-time screening for men ages 65 and older who have ever smoked

Alcohol Misuse - Screening and counseling

Colorectal Cancer - Screening for adults between the ages of 45 and 75, or for individuals under 50 with a family history of colon cancer

Cholesterol - Screening for adults of men over age 35, women over age 45, and other adults ages 20-35 at higher risk

Diabetes Type 2 - Screening for asymptomatic adults with sustained high blood pressure

Hepatitis B - Screening in adults at higher risk of infection

Hepatitis C - Screening in adults between the ages of 50 and 60, and those at higher risk of infection

HIV - Screening for all adults at higher risk

Lung Cancer - Annual Screening with low-dose computed tomography for adults ages 50-80 who have ever smoked

Preventive Office Visit - Such as an annual physical exam, which may include:

• Aspirin use counseling for men and women of certain ages
• Assessment and management to prevent falls in adults 65 and older
• Blood Pressure screening
• Depression screening
• Diet counseling for adults at higher risk for chronic disease
• Counseling for diet and exercise to prevent cardiovascular disease
• Obesity screening and counseling
• Counseling for minimizing risks of skin cancer in adults under age 24
• Counseling for adults at higher risk of Sexually Transmitted Infection (STI)
• Well woman visit to obtain women's preventive services

Syphilis - Screening for adults at higher risk

Tobacco Use - Screening and interventions for all adults

Vaccines - Recommendations vary for doses, ages, and populations:

• Hepatitis A
• Measles, Mumps, Rubella
• Hepatitis B
• Meningococcal
• Herpes Zoster
• Pneumococcal
• Human Papillomavirus
• Tetanus, Diphtheria, Pertussis
• Influenza
• Varicella

Anemia Screening - On a routine basis during pregnancy

Bacteriuria - Urinary tract or other infection screening in pregnant women

BRCA - Screening and genetic test counseling for women at higher risk for certain cancers

Breast Cancer Mammography - Screenings every 1 to 2 years for women over 40

Breast Cancer Preventive Medication - Counseling about risk-reducing medication for women at higher risk

Breastfeeding - Interventions to support/promote breastfeeding, including the purchase of some breast pumps

Cervical Cancer - Screening once every rolling 3 years. (3 years + 1 day)

Chlamydia - Screening for sexually active women and/or women at higher risk of infection

Colorectal Cancer - Screening for adults between the ages of 45 and 75, or for individuals under 50 with a family history of colon cancer

Contraceptives - Approved by the FDA and requiring a prescription

Domestic violence - Screening and counseling

Folic Acid Supplements - For women who may become pregnant

Gestational Diabetes - Screening for pregnant women

Gonorrhea - Screening for all women at higher risk of infection

Hepatitis B - Screening at the first prenatal visit

HIV - Testing for all pregnant women regardless of risk status

HPV - Testing one time every 5 years for women 30-65

Osteoporosis - Screening for women 65 and older or women under 65 that meet additional risk criteria

Pre-eclampsia prevention - Counseling on use of aspirin by pregnant women at higher risk

Rh Incompatibility - Screening and follow-up testing for women at higher risk

Syphilis - Screening for all pregnant women regardless of risk status

Tobacco Use - Expanded counseling for pregnant women

Well Woman - Annual visit to obtain women’s preventive services

Alcohol and Drug Use - Assessments for adolescents

Autism - Screening for children between their 9 months to 30-month doctor visits

Behavioral - Assessments

Cervical Dysplasia - Screening for sexually active females

Congenital Hypothyroidism - Screening for newborns

Dyslipidemia - Screening for children from ages 2-21 who are at higher risk of lipid disorders

Gonorrhea - Preventive medication for the eyes of all newborns

Hearing - Screening for all newborns

Hematocrit or Hemoglobin - Screening

Hemoglobinopathies - Or sickle cell screening for newborns

Hepatitis B - Screening for adolescents at higher risk for infection

HIV - Screening for adolescents at higher risk

Lead - Screening for children at risk of exposure

Newborn Blood Screening - Panel

Preventive Office Visit - Such as a well-child visit, which may include:

• Blood Pressure screening
• Depression screening for adolescents at higher risk
• Developmental screening for children under age 3, and surveillance throughout childhood
• Recommendation for fluoride chemoprevention supplements for children without fluoride in their water source
• Height, Weight, and Body Mass Index measurements
• Recommendation for iron supplements for children ages 6 to 12 months at risk for anemia
• Medical History
• Obesity screening and counseling
• Oral Health risk assessment for young children
• Recommendation for vision and hearing screening for children ages 3 to 5 years to detect amblyopia or its risk factors
• Counseling on minimizing risks for skin cancer
• Tobacco use intervention

Sexually Transmitted Infection (STI) - Prevention counseling and screening for adolescents at higher risk

Tuberculin - Testing for children at higher risk of tuberculosis

Vaccines - For children from birth to age 18—recommendations vary for doses, ages, and populations

• Diphtheria, Tetanus, Pertussis
• Influenza
• Measles, Mumps, Rubella
• Hepatitis A
• Meningococcal
• Hepatitis B
• Pneumococcal
• Human Papillomavirus
• Rotavirus
• Inactivated Poliovirus
• Varicella
• Haemophilus Influenzae Type b

Preventive services are services provided with the intent of identifying risk factors and screening for specific conditions. The goal is to prevent future health conditions. Preventive services do not include the evaluation or treatment of existing concerns. Health Tradition Health Plan follows federal guidelines for the reimbursement of defined preventive services, as outlined by the Affordable Care Act (ACA). 

Your plan covers 100% of the cost of preventive services, as long as the service is: 

• Provided by an In-Network Provider 
• Performed for preventive (not diagnostic) reasons; and 
• On the list of covered preventive services defined by the U.S. Preventive Services Task Force (USPSTF) and above

Each service you receive from your medical provider is submitted to us with a diagnosis and procedure code. The combination of these codes represents the service provided. If the service is identified as a preventive service and you use a network provider, you will not pay anything out-of-pocket.

If the diagnosis code represents the evaluation or treatment of a medical condition, then that service would be subject to applicable copay, deductible, or coinsurance.

Many vaccines are considered preventive, such as Hepatitis A, Measles, Mumps, Rubella, Hepatitis B, Meningococcal, Herpes Zoster, Pneumococcal, Human Papillomavirus, Tetanus, Diphtheria, Pertussis, Influenza and Varicella.

When services are provided to evaluate and manage an existing illness or condition, they are not considered preventive. For example, if you ask your provider about your knee pain and she evaluates and prescribes medication, you might have to pay for this additional, non-preventive service. Even if you are visiting your provider for a preventive care visit, ask to be sure all services provided are considered preventive.

If I go in for routine services to monitor an existing illness or condition?

No, routine services to monitor diabetes, hyperlipidemia, hyper cholesterol, etc. are not considered a preventive service. They are being done to evaluate and manage an existing illness or condition.

If I get a preventive lab/MRI from a Network Provider, but it gets sent to a non-Network Provider for the reading?

If the lab/MRI is billed as a preventive service and is rendered by a Network Provider, the reading with the non-Network Provider will be reimbursed at your Network benefits level. We will not apply any deductible or coinsurance; however, services are subject to the maximum allowable fee (MAF). Any charge above MAF will be your responsibility.

If I have a mammogram and it is determined that an MRI is needed for a more accurate screening due to fibrous or dense breast tissue?

Yes, an MRI of the breast would be considered a preventive service. Therefore, it is not subject to the applicable deductible and coinsurance, as long as you used a Network Provider.

If my physician orders a screening colonoscopy and polyps are found and removed?

Yes, as long as you used a Network Provider. Accurate coding by the clinic or facility is also necessary to identify the service as preventive.

Common Preventive Service Terms & Definitions

Visit: An appointment with the provider/doctor.

Service: Often performed during a visit, like an exam, labs, x-ray or counseling.

Routine: Routine means regularly scheduled, but does not necessarily mean preventive.

Preventive Services: Exams, tests, or procedures that help keep track of your health and wellbeing. You receive these services to prevent future health problems. You do not have signs or symptoms. 

Diagnostic Services: Services that evaluate new or established concerns. A service is considered diagnostic when the individual has signs or symptoms, or when an existing health issue is being monitored. Your deductible, coinsurance and copay might apply. 

Diagnostic vs. Preventive Service: An example is of Diagnostic Care is if a woman notices a lump in her breast and seeks a mammogram to check it out vs. Preventive Care where a woman receives a routine mammogram to screen for problems.