Preventive Services

Staying on top of your preventive care can help you:

  • Track vital numbers like your blood pressure and cholesterol level
  • Get immunizations to help you avoid illness
  • Catch potential health problems before they become serious

Under your health plan, you can get preventive care services at no additional cost.1 While all Kaiser Permanente service areas cover basic preventive care, you’ll find additional benefits in certain states and Washington, D.C. Read on to find out which services are available to you under a plan that begins on or after January 1, 2021.

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How to know if this information covers your plan

The information below doesn’t list services covered under Medicare. Instead, it applies to nongrandfathered individual and group plans (except retiree-only plans) and grandfathered group plans and retiree-only group plans that choose to cover preventive services.1

If you’re enrolled in grandfathered coverage or retiree-only coverage, see your Benefit Booklet, Evidence of Coverage, Certificate of Insurance, or Membership Agreement to find out which preventive services are covered.2 You can also talk to your employer’s benefits administrator.

This is a summary of the preventive benefit. Refer to your Benefit Booklet, Evidence of Coverage, Certificate of Insurance, or Membership Agreement for details about coverage.

What’s new for 2021

The following are benefit changes for 2021, as required by the Affordable Care Act (ACA). Most of our plans will now cover the following services:

  • Anxiety screening for adolescent and adult women (will be covered for plan years or policy years beginning on or after January 1, 2021)
  • Unhealthy drug use screening in adults 18 and older (will be covered for plan years or policy years beginning on or after January 1, 2021) 

In addition, Kaiser Permanente made the decision to add the following lab tests and screenings for specific chronic conditions allowed by the Internal Revenue Service (IRS) Notice 2019-45 to Kaiser Permanente’s National Preventive Care package, effective all at once, on January 1, 2021.3 As a result, these changes will apply not only to high deductible health plans (HDHP), but to all nongrandfathered plans and to grandfathered plans that have adopted the ACA preventive care package. The following lab tests and screenings for specific chronic conditions will be covered at no additional cost: 

  • Hemoglobin A1c testing for the chronic condition of diabetes (will be covered for plan years or policy years beginning on or after January 1, 2021) 
  • International normalized ratio (INR) testing for the chronic condition of liver disease and/or bleeding disorders (will be covered for plan years or policy years beginning on or after January 1, 2021) 
  • Low-density lipoprotein (LDL) testing for the chronic condition of heart disease (will be covered for plan years or policy years beginning on or after January 1, 2021) 
  • Retinopathy screening for the chronic condition of diabetes (will be covered for plan years or policy years beginning on or after January 1, 2021)

Preventive services for adults

  • Abdominal aortic aneurysm screening (one time for men 65 to 75 who have ever smoked)
  • Age-appropriate preventive medical examinations
  • Annual lung cancer screening with low-dose computed tomography, and counseling, for adults 55 to 80 who are at high risk based on their current or past smoking history
  • Blood pressure screening
  • Colon cancer screening (for adults 50 to 75)
    • Bowel preparation medications prescribed prior to a screening colonoscopy
    • Pathology exam on a polyp biopsy, performed in connection with colon cancer screening
    • Preconsultation visit associated with colon cancer screening
  • Depression screening
  • Diabetes screening (type 2) for adults with abnormal blood glucose
  • Discussions with primary care physician about:
    • Alcohol misuse screening and counseling
    • Diet, if at higher risk for chronic disease
    • Low-dose aspirin use, if at high risk of cardiovascular disease or colorectal cancer
    • Obesity and weight management, including intensive behavioral counseling for overweight adults at risk for cardiovascular disease
    • Sexually transmitted infections prevention
    • Tobacco use cessation and counseling
  • FDA-approved medications for tobacco cessation, including over-the-counter medications, when prescribed by a plan provider
  • FDA-approved preexposure prophylaxis (PrEP) with effective antiretroviral therapy to persons at high risk of HIV acquisition, when prescribed by a plan provider
  • Hepatitis B screening (for adults at higher risk)
  • Hepatitis C screening (for adults 18 to 79 years)
  • Immunizations (doses, recommended ages, and recommended populations vary):
    • Hepatitis A
    • Hepatitis B
    • Herpes zoster
    • Human papillomavirus
    • Influenza
    • Measles, mumps, rubella
    • Meningococcal (meningitis)
    • Pneumococcal
    • Tetanus, diphtheria, pertussis
    • Varicella
  • Latent tuberculosis infection screening
  • Over-the-counter drugs when prescribed by your doctor for preventive purposes:
    • Low-dose aspirin to prevent colorectal cancer
    • Low-dose aspirin to reduce the risk of heart attack
  • Physical therapy to prevent falls (in community-dwelling adults 65 and older who are at increased risk of falling)
  • Routine physical exam
  • Sexually transmitted infection screenings (for adults at higher risk)
    • Chlamydia
    • Gonorrhea
    • HIV
    • Syphilis
  • Statin use for the primary prevention of cardiovascular disease in adults 40 to 75 years with no history of cardiovascular disease (CVD), one or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater
  • Universal lipids screening in adults 40 to 75 years to identify dyslipidemia and a calculation of a 10-year CVD risk

Additional preventive services for women4

  • Anemia screening (for pregnant women)5
  • BRCA genetic counseling to assess risk of carrying breast/ovarian cancer genes (for those who meet U.S. Preventive Services Task Force guidelines)
  • BRCA genetic testing (for high-risk women and when services are ordered by a plan physician)
  • Breastfeeding equipment
  • Cancer screening:
    • Breast cancer (mammography for women 40 and older)
    • Cervical cancer (for women 21 to 65)
  • Contraceptive devices, methods, and drugs (FDA-approved and prescribed by your doctor), contraceptive device removal, and female sterilizations
  • Counseling intervention for pregnant or postpartum persons at increased risk of perinatal depression
  • Discussions with primary care physician about:
    • Breastfeeding and comprehensive lactation support
    • Chemoprevention for breast cancer (if at higher risk)
    • Contraceptive methods
    • Family history of breast and/or ovarian cancer
    • Folic acid supplements (a daily supplement of 0.4 to 0.8 milligrams of folic acid if you are capable or planning pregnancy)
    • Interpersonal and domestic violence
    • Preconception care
    • Tobacco use cessation and counseling for pregnant women
  • FDA-approved medications for tobacco cessation for pregnant women, including over-the-counter medications, when prescribed by a plan provider6
  • Gestational diabetes screening (for pregnant women at high risk, or women 24 and 28 weeks pregnant)
  • Hepatitis B screening (for pregnant women at their first prenatal visit)
  • HIV screening for pregnant women
  • Low-dose aspirin (after 12 weeks of gestation in women who are at high risk for preeclampsia)
  • Osteoporosis screening (for women 65 and older, and those at higher risk)
  • Over-the-counter folic acid (a daily supplement of 0.4 to 0.8 milligrams of folic acid for women who are capable or planning pregnancy to reduce the risk of birth defects when prescribed by a doctor for preventive purposes)
  • Preeclampsia screening (for pregnant women with blood pressure measurements during pregnancy)
  • Prescribed, FDA-approved medications for breast cancer prevention (if at higher risk, 35 and older with no prior history of breast cancer)
  • Rh incompatibility screening (for pregnant women) and follow-up testing (for those at higher risk)
  • Routine physical exam
  • Routine prenatal care visits7
  • Screening for diabetes mellitus after pregnancy
  • Screening for urinary incontinence in women
  • Syphilis screening for pregnant women
  • Urinary tract or other infection screening (for pregnant women)

Preventive services for children

  • Age-appropriate preventive medical examinations
  • Autism screening by primary care physician (at 18 months and 24 months)
  • Behavioral assessments by primary care physician (throughout development)
  • Blood pressure screening for adolescents
  • Cervical dysplasia screening (for sexually active females)
  • Congenital hypothyroidism screening (newborns)
  • Depression screening (for adolescents 12 to 18 years)
  • Developmental screening (under 3 years) and surveillance (throughout childhood) by primary care physician
  • Discussions with primary care physician about:
    • Alcohol and drug use counseling for adolescents
    • Fluoride supplements for children who have no fluoride in their water source
    • Iron supplements for children 6 months to 12 months at risk for anemia
    • Obesity screening and counseling
    • Sexually transmitted infection prevention counseling for adolescents at higher risk
    • Skin cancer counseling for young adults, adolescents, children, and parents of young children about minimizing exposure to ultraviolet (UV) radiation for persons 6 months to 24 years with fair skin types to reduce their risk of skin cancer
    • Tobacco use cessation and counseling
  • Dyslipidemia screening (for children at higher risk of lipid disorders)
  • FDA-approved medications for tobacco cessation, including over-the-counter medications, when prescribed by a plan provider
  • Gonorrhea prevention medication for the eyes (newborns)
  • Hearing screening (newborns)
  • Height, weight, and body mass index (BMI) measurements (throughout development)
  • Hematocrit or hemoglobin screening
  • Hemoglobinopathies or sickle cell screening (newborns)
  • Hepatitis B screening (for adolescents at higher risk)
  • HIV screening (for adolescents at higher risk)
  • Immunizations (from birth to 18 years; doses, recommended ages, and recommended populations vary):
    • Diphtheria, tetanus, pertussis
    • Haemophilus influenzae type B
    • Hepatitis A
    • Hepatitis B
    • Human papillomavirus
    • Inactivated poliovirus
    • Influenza
    • Measles, mumps, rubella
    • Meningococcal (meningitis)
    • Pneumococcal
    • Rotavirus
    • Varicella
  • Lead screening (for children at risk of exposure)
  • Medical history (throughout development)
  • Oral health risk assessments by primary care physician
    • Fluoride supplementation starting at 6 months for children who have no fluoride in their water source
    • Fluoride varnish for the primary teeth of all infants and children starting at the age of primary tooth eruption
  • Over-the-counter drugs when prescribed by your doctor for preventive purposes:
    • Iron supplements for children to reduce the risk of anemia
    • Oral fluoride for children to reduce the risk of tooth decay
  • Phenylketonuria screening (newborns)
  • Routine physical exam
  • Tuberculin testing (for children at higher risk of tuberculosis)
  • Vision screening

Additional region-specific preventive services8

For health plans issued in one of these states, additional region specific preventive services are also listed for that state.

California

  • Artificial insemination and sperm collection, processing, and testing for HIV-negative women who wish to conceive using sperm from HIV-positive donors
  • Postpartum visits9
  • Prostate cancer screenings (e.g., prostate-specific antigen testing and digital rectal examination)
  • Retinal photography screenings for adults and children
  • Travel immunizations

Colorado

  • Annual mental wellness checkup for all individuals regardless of age10
  • Breast cancer screening for all at-risk individuals regardless of age
  • Colon cancer screening for all at-risk individuals regardless of age
  • Prostate cancer screenings

Georgia

  • Medically necessary labs and X-rays associated with a well-child visit
  • Ovarian cancer surveillance test for women over 35 or at risk
  • Prostate cancer screenings

Maryland

  • Labs and X-rays associated with well-child visits
  • Prostate cancer screenings

Oregon

  • Coverage for condoms, regardless of the gender or sexual orientation of the covered person, and regardless if they are to be used for contraception or specifically to prevent a sexually transmitted disease
  • First postpartum visit 
  • Medically necessary services and prescription medications for the treatment of physical, mental, sexual, and reproductive health care needs that arise from a sexual assault 
  • Prostate cancer screenings Screening following a sexual assault

Virginia

  • Labs and X-rays associated with well-child visits
  • Prostate cancer screenings

Washington

  • Postpartum visits
  • Prostate cancer screenings

Washington — SW region

  • Postpartum visits 
  • Coverage for condoms, regardless of the gender or sexual orientation of the covered person, and regardless if they are to be used for contraception or specifically to prevent a sexually transmitted disease 
  • Medically necessary services and prescription medications for the treatment of physical, mental, sexual, and reproductive health care needs that arise from a sexual assault 
  • Prostate cancer screenings 
  • Screening following a sexual assault 

Washington, D.C.

  • Adjuvant breast screening (follow-up breast MRI or ultrasound for women with dense breast tissue, after an inconclusive mammogram, or deemed high risk by their provider) 
  • Labs and X-rays associated with well-child visits
  • Prostate cancer screenings

Disclaimers
[1] The preventive services described above also apply to all grandfathered and retiree-only large group plans that cover these services at no additional cost and all grandfathered small group plans in the state of California.
[2] Grandfathered plans are plans that have been in existence since, on, or before March 23, 2010, and that meet certain requirements. Grandfathered plans are exempt from some of the changes required under the Affordable Care Act, including those related to preventive services, and may have a cost share associated with these services. If a member is enrolled in a grandfathered plan, this will be stated in their Membership Agreement, Disclosure Form, and Evidence of Coverage or Certificate of Insurance. Also, grandfathered plans may not cover all services listed in this document, such as over-the-counter drugs. Members enrolled in grandfathered plans can also contact our Member Service Contact Center at 1-800-464-4000 (TTY 711), 24 hours a day, 7 days a week (closed holidays), to inquire into their plan’s coverage of specific preventive care services.
[3] On July 17, 2019, the Internal Revenue Service (IRS) and U.S. Treasury Department issued Notice 2019-45, which expands the list of preventive care benefits permitted to be provided without satisfying the deductible of an HDHP under section 223(c)(2) of the Internal Revenue Code. Kaiser Permanente made the decision to add all these lab tests and screenings for specific chronic conditions allowed by IRS Notice 2019-45 to Kaiser Permanente’s National Preventive Care package, effective all at once, on January 1, 2021.
[4] Breast pumps and certain over-the-counter drugs may not be covered in plans that do not include an ACA preventive package (see your Evidence of Coverage, Membership Agreement, or Certificate of Insurance for details).
[5] In September 2015, the U.S. Preventive Services Task Force determined that current evidence is insufficient to assess the balance of benefits and harms of screening of iron deficiency in pregnant women to prevent adverse maternal health and birth outcomes. Despite this determination, Kaiser Permanente will continue to cover this service as preventive.
[6] In September 2015, the U.S. Preventive Services Task Force determined that current evidence is insufficient to assess the balance of benefits and harms of pharmacotherapy interventions for tobacco cessation in pregnant women. Despite this determination, Kaiser Permanente will continue to cover this service as preventive.
[7] Prenatal services are covered as routine base medical services that are included in global billing for maternity services, which may be subject to cost sharing, as permitted by applicable law.
[8] Most self-funded groups are not subject to state mandates. Some self-funded state and local government groups may not be subject to state mandates. For more information, see your Summary Plan Description or talk to your employer’s benefits administrator.
[9] In California health savings account compliant plans, the first postpartum visit is subject to the deductible and may be subject to a copay or coinsurance after the deductible has been met.
[10] Effective January 1, 2020, health plans must cover an annual mental wellness checkup for all individuals regardless of age. The applicable cost share for this service may apply to grandfathered plans.

The required preventive services are based on recommendations by the U.S. Preventive Services Task Force (uspreventiveservicestaskforce.org), the Health Resources and Services Administration (hrsa.gov), and the Centers for Disease Control and Prevention (cdc.gov). The services listed in this document may be subject to certain guidelines, such as age and frequency. They may be subject to cost sharing if they are not provided in accord with these guidelines.