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2022 Preventive Health Care Guidelines for Individual & Family Plan members

 

Be Informed

We want to help you understand and take advantage of your preventive coverage for things like routine exams, flu shots and well-child visits: helping you stay well and healthy is at the center of everything we do.

This guide will help you understand the differences between preventive and diagnostic care to help you make informed health care decisions and avoid unexpected costs.

If you have questions about covered services or any potential costs to you, call UCare Customer Services at the number on the back of your UCare member ID card.


 

What is preventive care?

Preventive care lets your doctor find potential health problems before you feel sick, when many issues are easier to treat. This is why it’s important to visit your doctor regularly to stay healthy. Some services provided as preventive include:

  • Immunizations for adults and children
  • Annual physical exams
  • Routine pre-natal and post-natal visits
  • Certain lab tests
  • Screenings for certain types of cancer

The preventive services listed in these guidelines are at no additional cost when you see an in-network provider. To find health care providers who are part of UCare’s network, search the network.

These guidelines may change throughout the coverage year based on new research and recommendations.

Be informed:

In-network and non-network care
Getting care from in-network providers and facilities is one way to help manage your health care costs. It’s important to understand that your in-network provider may sometimes provide care at non-network clinics or hospitals. Whenever possible, ask about the network status of providers, facilities and support staff before office visits or procedures.

The preventive services UCare offers are based on guidelines from the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP), the Centers for Disease Control and Prevention (CDC), the Health Resources and Services Administration (HRSA), and the Bright Futures/American Academy of Pediatrics Periodicity Schedule.


 

What is diagnostic care?

A service or test is diagnostic when it monitors, diagnoses or treats an existing health problem. If you have a chronic disease such as diabetes, your doctor may monitor your condition with tests. Or you may go to your doctor with a symptom such as a stomachache. In each of these cases, any tests or services would be diagnostic because they are used to treat an existing condition or as a follow-up to symptoms you have.

How do I know if a service is preventive or diagnostic?

The key difference between a preventive and diagnostic test is whether it is done before you have any symptoms.

The same service from your doctor could be preventive or diagnostic, depending on the circumstances. If the service or test is diagnostic, you will be responsible for any out-of-pocket costs that apply. In general:

  • If you have an existing condition, your doctor will monitor your condition with tests. Because these tests manage your condition, they’re diagnostic.
  • If you have a preventive screening and a health condition shows up, your doctor may order follow-up tests. In this case, the tests are diagnostic.
  • If your doctor orders tests based on symptoms you’re having, these tests are diagnostic.

Preventive vs diagnostic

Understand your coverage

It’s important to remember that preventive and diagnostic care can happen during the same doctor visit. For example, let’s imagine your doctor checks your blood sugar level. If you do not have diabetes, this test would be considered preventive. However, if you have previously been diagnosed with diabetes, it would be diagnostic since the test is monitoring an existing condition. You would be responsible for out-of-pocket costs in this instance.

The more you know about your health coverage, including the difference between preventive and diagnostic care, the better your health care decisions will be and the fewer surprises you’ll have when statements or bills arrive.

Any time you have questions about your coverage, call Individual & Family Plans Customer Services at the number on the back of your UCare member ID card.

 

Examples of preventive and diagnostic services

Services It's preventive (at no additional cost) when... It's diagnostic when...
Colon cancer screening Your doctor wants to screen for signs of colon cancer based on your age or family history. If a polyp is found and removed during the screening, the colonoscopy, polyp removal and testing are preventive. You’re having a health problem, such as bleeding or irregularity.
Complete blood count (CBC) Never preventive. Always diagnostic. Studies show there’s no need for this test unless you have symptoms.
Diabetes screening A blood glucose test is used to detect problems with your blood sugar, even though you don’t have symptoms. You’ve been diagnosed with diabetes and your doctor checks your A1c.
Metabolic panels Never preventive. Always diagnostic. Studies show that a metabolic test isn’t useful for detecting or preventing illnesses.
Osteoporosis screening Your doctor recommends a bone density test based on your age or family history. You’ve had a health problem or your doctor wants to determine the success of a treatment.
Thyroid tests Done as part of newborn screening within the first 90 days from birth as required by state mandate. An adult has symptoms, according to national guidelines.
Urinalysis A urine culture is used to screen pregnant women at 12-16 weeks’ gestation or at the first prenatal visit, if later, for bacteria in the urine, according to United States Preventive Services Task Force (USPSTF) recommendations. Symptoms are present, according to national guidelines.

 

Children’s health


 

Adult health


 

Women’s health

In addition to the preventive services listed in the Adult Health section, women are also eligible for the following preventive services:


 

Pregnant women

If you’re currently pregnant, are thinking about becoming pregnant or have recently had a baby, these preventive care recommendations are covered in addition to the services listed in the Adult Health and Women’s Health sections. Be aware that your doctor may offer additional tests, screenings or services (for example, high-risk prenatal services). These additional services are not part of the preventive services covered by health plans and you may be responsible for out-of-pocket costs.