Preventive Care and Screenings

We will pay for a one-time ultrasound screening for people at risk. The plan only covers this screening if you have certain risk factors and if you get a referral for it from your physician, physician assistant, nurse practitioner, or clinical nurse specialist.

We will pay for one alcohol-misuse screening (SBIRT) and counseling (AMSC) for adults who misuse alcohol but are not alcohol dependent. This includes pregnant women. If you screen positive for alcohol misuse, you can get up to four brief, face-to-face counseling sessions each year (if you are able and alert during counseling) with a qualified primary care provider or practitioner in a primary care setting. 

We encourage you to get an annual checkup. This is to make or update a prevention plan based on your current risk factors. We will pay for this once every 12 months.
 

We will pay for certain procedures for members who qualify (usually, someone at risk of losing bone mass or at risk of osteoporosis). These procedures identify bone mass, find bone loss, or find out bone quality. We will pay for the services once every 24 months, or more often if they are medically necessary. We will also pay for a doctor to look at and comment on the results.

We will pay for the following services: 

• One baseline mammogram between the ages of 35 and 39 
• One screening mammogram every 12 months for women age 40 and older 
• Clinical breast exams once every 24 months

We pay for blood tests to check for cardiovascular disease once every five years (60 months). These blood tests also check for defects due to high risk of heart disease. 

You should talk to your provider and get a referral.

We will pay for the following services: 

• For all women: Pap tests and pelvic exams once every 24 months 
• For women who are at high risk of cervical or vaginal cancer: one Pap test every 12 months 
• For women who have had an abnormal Pap test within the last 3 years and are of childbearing age: one Pap test every 12 months 
• For women aged 30-65: human papillomavirus (HPV) testing or Pap plus HPV testing once every 5 years

For people 50 and older, we will pay for the following services:

• Flexible sigmoidoscopy (or screening barium enema) every 48 months 
• Fecal occult blood test, every 12 months
• Guaiac-based fecal occult blood test or fecal immunochemical test, every 12 months 
• DNA based colorectal screening, every 3 years 
• Colonoscopy every ten years (but not within 48 months of a screening sigmoidoscopy) 
• Colonoscopy (or screening barium enema) for people at high risk of colorectal cancer, every 24 months.

If you use tobacco, do not have signs or symptoms of tobacco-related disease, and want or need to quit: 

• We will pay for two quit attempts in a 12-month period as a preventive service. This service is free for you. Each quit attempt includes up to four counseling face-to-face visits.

If you use tobacco and have been diagnosed with a tobacco-related disease or are taking medicine that may be affected by tobacco: 

• We will pay for two counseling quit attempts within a 12-month period. Each counseling attempt includes up to four face-to-face visits. 

If you are pregnant, you may get unlimited tobacco cessation counseling with prior authorization.

We will pay for this screening (includes fasting glucose tests) if you have any of the following risk factors: 

• High blood pressure (hypertension) 
• History of abnormal cholesterol and triglyceride levels (dyslipidemia) 
• Obesity
• History of high blood sugar (glucose) 

Tests may be covered in some other cases, such as if you are overweight and have a family history of diabetes. Depending on the test results, you may qualify for up to two diabetes screenings every 12 months

We will pay for the following services for all people who have diabetes (whether they use insulin or not): 

Supplies to monitor your blood glucose, including the following: 

• A blood glucose monitor 
• Blood glucose test strips
• Lancet devices and lancets 
• Glucose-control solutions for checking the accuracy of test strips and monitors 

For people with diabetes who have severe diabetic foot disease, we will pay for the following:

• One pair of therapeutic custom-molded shoes (including inserts), including the fitting, and two extra pairs of inserts each calendar year, or 
• One pair of depth shoes, including the fitting, and three pairs of inserts each year (not including the non-customized removable inserts provided with such shoes) 

We will pay for training to help you manage your diabetes, in some cases. To find out more, contact Member Services. 

Members with Diabetes are eligible for the L.A. Cares About Diabetes® program. This is a free program to help members control their diabetes, including:

• Diabetes health materials
• Diabetes classes for you and your family 
• Nurses to: 
  • Coach you to learn how to control blood sugar levels 
  • Review your diabetes medicines 
  • Guide you on healthy eating 
  • Give tips for talking with your doctor about diabetes 

You should talk to your provider and get a referral.

We pay for one HIV screening exam every 12 months for people who: 

• Ask for an HIV screening test, or 
• Are at increased risk for HIV infection. 

For women who are pregnant, we pay for up to three HIV screening tests during a pregnancy.

We will also pay for additional HIV screening(s) when recommended by your provider.

We will pay for the following services: 

• Pneumonia vaccine 
• Flu shots, once each flu season in the fall and winter, with additional flu shots if medically necessary
• Hepatitis B vaccine if you are at high or intermediate risk of getting hepatitis B 
• COVID-19 Vaccine
• Other vaccines if you are at risk and they meet Medicare Part B coverage rules 

We will pay for other vaccines that meet the Medicare Part D coverage rules. Read Chapter 6 to learn more.

We also pay for all vaccines for adults as recommended by the Advisory Committee on Immunization Practices (ACIP).

The plan will pay for lung cancer screening every 12 months if you:

• Are aged 50-80, and 
• Have a counseling and shared decision-making visit with your doctor or other qualified provider, and 
• Have smoked at least 1 pack a day for 20 years with no signs or symptoms of lung cancer or smoke now or have quit within the last 15 years. 

After the first screening, the plan will pay for another screening each year with a written order from your doctor or other qualified provider.

This benefit is for people with diabetes or kidney disease without dialysis. It is also for after a kidney transplant when referred or ordered by your doctor. 

We will pay for three hours of one-on-one counseling services during your first year that you get medical nutrition therapy services under Medicare. (This includes our plan, any other Medicare Advantage plan, or Medicare.) We may approve additional services if medically necessary. 

We will pay for two hours of one-on-one counseling services each year after that. If your condition, treatment, or diagnosis changes, you may be able to get more hours of treatment with a doctor’s referral or order. A doctor must prescribe these services and renew the referral or order each year if your treatment is needed in the next calendar year. We may approve additional services if medically necessary.

The plan will pay for MDPP services. MDPP is designed to help you increase healthy behavior. It provides practical training in:

• long-term dietary change, and
• increased physical activity, and 
• ways to maintain weight loss and a healthy lifestyle. 

You should talk to your provider and get a referral.

If you have a body mass index of 30 or more, we will pay for counseling to help you lose weight. You must get the counseling in a primary care setting. That way, it can be managed with your full prevention plan. Talk to your primary care provider to find out more.
 

For men age 50 and older, we will pay for the following services once every 12 months: 

• A digital rectal exam 
• A prostate specific antigen (PSA) test

We will pay for screenings for chlamydia, gonorrhea, syphilis, and hepatitis B. These screenings are covered for pregnant women and for some people who are at increased risk for an STI.

 A primary care provider must order the tests. We cover these tests once every 12 months or at certain times during pregnancy. 

We will also pay for up to two face-to-face, high-intensity behavioral counseling sessions each year for sexually active adults at increased risk for STIs. Each session can be 20 to 30 minutes long. 

We will pay for these counseling sessions as a preventive service only if they are given by a primary care provider. The sessions must be in a primary care setting, such as a doctor’s office.

We will pay for outpatient doctor services for the diagnosis and treatment of diseases and injuries of the eye. For example, this includes annual eye exams for diabetic retinopathy for people with diabetes and treatment for age-related macular degeneration. 

For people at high risk of glaucoma, we will pay for one glaucoma screening each year. People at high risk of glaucoma include:

• People with a family history of glaucoma 
• People with diabetes
• African-Americans who are age 50 and older 
• Hispanic Americans who are 65 or older 

We will pay for one pair of glasses or contact lenses after each cataract surgery when the doctor inserts an intraocular lens. (If you have two separate cataract surgeries, you must get one pair of glasses after each surgery. You cannot get two pairs of glasses after the second surgery, even if you did not get a pair of glasses after the first surgery).

We cover the one-time “Welcome to Medicare” preventive visit. The visit includes: 

• A review of your health
• Education and counseling about the preventive services you need (including screenings and shots), and 
• Referrals for other care if you need it

Note: We cover the “Welcome to Medicare” preventive visit only during the first 12 months that you have Medicare Part B. When you make your appointment, tell your doctor’s office you want to schedule your “Welcome to Medicare” preventive visit.

Remember: Talk to YOUR primary care provider to determine if you’re due for any preventive services.