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Important Preventive Care Services Covered by the Health Plan

It is safe to assume that most people don’t want to go to the doctor. Many wait to go until they experience symptoms or hold out altogether, choosing instead to bear their pain or discomfort. This approach to health care, however, is often dangerous.

In fact, going to the doctor before an illness arises—for annual physicals and other preventive care—helps to prevent emergency room visits and can avoid the higher medical costs of treating serious conditions (e.g., heart attacks, cancers, etc.) down the line.

How? The Health Plan covers certain preventive care services—medical services that have been proven to help people avoid chronic and acute illness—at 100% with no deductibles or co-payment if the services are administered by a network provider, as long as the services are medically necessary and you meet the age, risk or frequency requirements for the services. Preventive care services provided by a non-network provider will be paid at the applicable non-network co-insurance level.

If you are receiving your preventive annual screening, also referred to as an annual physical, it will be covered at 100% as long as it is administered by a network provider and the provider bills the services as preventive. It is recommended when making this type of appointment to indicate to your provider that the visit is for your “annual preventive screening.”

Other examples of preventive services covered at 100% include colonoscopies, screenings for chronic illnesses (e.g., mammograms, HIV screenings and obesity screenings), child and adult immunizations and more.

It is important to also note that preventive care services do not include services to treat or diagnose an illness. If during a preventive care screening you also receive treatment or diagnostic services to address a specific medical condition or concern, the non-preventive portion of the visit will be subject to your applicable co-insurance, co-payment and out-of-pocket costs. The preventive services, however, will be paid at 100%, with no deductible when provided by a network doctor.

Below are examples of certain preventive care services that are covered at 100% for Health Plan participants.

Avoid Unexpected Charges for Preventive Care Services

To ensure your preventive care services are paid at 100%, make sure you:

  • Have a network provider complete the services.
  • Keep a calendar or journal of when your services are completed and/or due.
  • Contact the Health Plan’s Participant Services Department with questions about your potential costs or the timing of services at (323) 866-2200, Ext. 401.

For more information about the Health Plan’s preventive care benefits and a full list of preventive care services, see page 74 of the Health Plan SPD at www.dgaplans.org/health-plan-booklet.