CurrentAmbetter NevadaPolicy N/A

Preventive Care Guide

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This guide explains federal preventive-care coverage for Ambetter Health plans, including covered screenings, counseling, immunizations, preventive medications, wellness examinations, and related services. Covered preventive services are generally available without member cost sharing when provided by an in-network provider, while diagnostic services may be subject to applicable medical-benefit cost sharing.

Policy Summary

PayerAmbetter Nevada

PolicyPreventive Care Guide

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionReport covered services as preventive when they are performed for preventive screening, the member has no symptoms or abnormal findings, and the service is within the recommended interval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%In-network preventive care covered without deductible, coinsurance, or copayment

A or BUSPSTF preventive-service rating threshold

45-75Adult colorectal screening age range

50-80

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CurrentAmbetter NevadaPolicy N/A

Preventive Care Guide

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Sign up for all Ambetter Nevada policy alerts

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Policy Summary

PayerAmbetter Nevada

PolicyPreventive Care Guide

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionReport covered services as preventive when they are performed for preventive screening, the member has no symptoms or abnormal findings, and the service is within the recommended interval.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

100%In-network preventive care covered without deductible, coinsurance, or copayment

A or BUSPSTF preventive-service rating threshold

45-75Adult colorectal screening age range

50-80

Annual lung cancer screening age range when criteria are met

21-65Average-risk cervical screening age range

Preventive Services Coverage Criteria

Eligible preventive services

Covered preventive services include services supported by the following recommendations and benefit categories:

Eligible preventive-service source: The service is an evidence-based USPSTF A/B recommendation; an ACIP-recommended routine immunization; an HRSA-supported preventive service for women; an HRSA-supported Bright Futures service for infants, children, or adolescents; tobacco-cessation treatment; a wellness examination; or a service integral to furnishing a specific preventive benefit.

If two recommendations address the same benefit, the richer benefit applies.

Preventive benefit and no cost sharing

The no-cost-share preventive benefit applies when ALL of the following are met.

Preventive benefit conditions

The service is recommended or otherwise included as preventive care.
It is performed for preventive screening or prevention rather than diagnosis or treatment.
It is appropriately reported as preventive.
It is provided by an in-network Ambetter Health provider.

Preventive versus diagnostic classification

A service is treated as preventive when at least one of the following applicable conditions is met:

Preventive screening context

The member has not previously received the screening and has no symptoms or abnormal findings suggesting an abnormality.
The member has had the preventive screening within the recommended interval and the findings were normal.
Prior diagnostic results were normal and the physician recommends future screening at preventive intervals.

Reasonable medical management

Reasonable medical management may be used when ALL of the following circumstances apply.

Coverage limitation management

A recommendation or guideline does not specify the frequency, method, treatment, or setting of the recommended preventive service.
The plan uses a reasonable medical management technique to determine the applicable limitation.

Colorectal cancer screening

Colorectal cancer screening is covered for adults aged 45-75 years when one of the following recommended testing approaches and intervals is used:

Colorectal screening options

High-sensitivity guaiac fecal occult blood test or fecal immunochemical test every year.
Stool DNA-FIT every 1 to 3 years.
CT colonography every 5 years.
Flexible sigmoidoscopy every 5 years.
Flexible sigmoidoscopy every 10 years plus annual FIT.
Colonoscopy every 10 years.

Cervical cancer screening

Cervical cancer screening is covered for women aged 21-65 years using the age-appropriate method below:

Cervical screening options

For women aged 21-29 years, cervical cytology alone every 3 years.
For women aged 30-65 years, cervical cytology alone every 3 years.
For women aged 30-65 years, high-risk HPV testing alone every 5 years.
For women aged 30-65 years, cotesting with high-risk HPV and cytology every 5 years.

Lung cancer screening

Lung cancer screening is covered when ALL criteria are met.

LDCT lung cancer screening

The individual is 50-80 years old.
The individual has at least a 20 pack-year smoking history.
The individual currently smokes or quit within the past 15 years.

Population and risk-based screening

Selected screening and intervention benefits apply when the individual meets the population and clinical risk criteria specified by the applicable recommendation.

Population-specific preventive criteria

The individual falls within the population and risk or pregnancy criteria specified by the applicable recommendation, such as pregnancy for gestational diabetes, hepatitis B, hypertensive-disorder, preeclampsia, Rh(D), or syphilis screening; increased risk for latent tuberculosis, sexually transmitted infection, HIV, osteoporosis, breast cancer, or falls; or the specified age, sex, smoking, BMI, or pregnancy status for the service.

Adult and child screening recommendations

The following services are recommended for the specified populations when the listed clinical conditions are met:

Screen adults aged 18 years or older for hypertension using office blood pressure measurement, with out-of-office measurement for diagnostic confirmation before treatment.
Screen women of reproductive age for intimate partner violence.
Provide annual LDCT lung cancer screening for eligible adults.
Screen adults aged 35-70 years who are overweight or obese for prediabetes and type 2 diabetes.
Provide visual impairment screening at least once in children aged 3-5 years.

Obesity and breast cancer prevention

Offer or refer when the individual meets the applicable population and clinical criteria.

Behavioral and breast cancer prevention

The adult has a BMI of 30 or higher and is offered or referred to intensive multicomponent behavioral interventions.BMI >= 30
The individual is an average-risk woman eligible for screening mammography, beginning no earlier than age 40 and no later than age 50, at least biennially and as frequently as annually.Mammography generally begins age 40-50 and continues through at least age 74
Additional imaging or pathology evaluation is indicated to complete the breast cancer screening process or evaluate findings.

Women's preventive and reproductive services

Provide preventive women's services according to the population, risk, and clinical circumstances described.

Women's preventive services

Provide comprehensive lactation support during antenatal, perinatal, and postpartum periods.
Provide breastfeeding equipment and supplies as clinically indicated, prioritizing double electric pumps without requiring prior manual-pump failure.
Provide the full range of FDA-approved, granted, or cleared contraceptives and contraceptive care, including screening, education, counseling, provision, follow-up, removal, continuation, discontinuation, and fertility-awareness counseling.
Provide STI counseling to sexually active adolescent and adult women at increased risk.
Provide individualized obesity-prevention counseling to appropriate midlife women.

Women's behavioral health and navigation

Screen and provide intervention or referral when indicated.

Violence, anxiety, and navigation services

Provide patient navigation for breast and cervical cancer screening and follow-up based on assessed needs.
Screen adolescent and adult women for intimate partner and domestic violence at least annually and provide or refer for intervention when needed.At least annually
Screen adolescent and adult women, including pregnant and postpartum women, for anxiety using clinical judgment because optimal intervals are unknown.
Intervention may include counseling, education, harm reduction strategies, and supportive services.

Women's cancer, diabetes, pregnancy, and HIV screening

Apply age, pregnancy, postpartum, and prior-result criteria.

Screen average-risk women aged 21-65 years for cervical cancer.
Screen women with prior gestational diabetes for type 2 diabetes after pregnancy when they are not pregnant and have not previously been diagnosed with type 2 diabetes.
Screen pregnant women for gestational diabetes after 24 weeks, preferably at 24-28 weeks, and earlier when risk factors for type 2 diabetes or gestational diabetes are present.Preferably 24-28 weeks of gestation
Provide HIV screening at least once for adolescent and adult women aged 15 years and older, with additional or annual screening based on risk.Age 15 years and older

Bright Futures pediatric preventive services

Provide age- and risk-appropriate pediatric preventive services.

Pediatric preventive care

Provide anemia screening through age 22.
Provide depression screening at recommended visits from ages 12-21 and integrate maternal postpartum depression screening into well-child visits at 1, 2, 4, and 6 months.
Perform dyslipidemia, developmental/autism, HIV, STI, tuberculosis, visual, hearing, lead, psychosocial/behavioral, and substance-use risk assessments or screening at the listed ages.
Provide fluoride varnish for high-risk children and age-appropriate hearing and vision screening.

Routine pediatric immunizations

Administer routine immunizations according to age, prior vaccination, risk, travel, and ACIP recommendations.

Pediatric immunizations

Provide age-appropriate varicella, DTaP/Tdap, Hib, hepatitis A, hepatitis B, HPV, inactivated poliovirus, influenza, MMR, meningococcal, pneumococcal, rotavirus, COVID-19, and RSV immunization recommendations.
Use catch-up or risk-based schedules for older children and adolescents who lack prior vaccination or have increased risk.

Adult immunizations

Provide adult immunization based on immunity, age, travel, exposure risk, and prior vaccination.

Provide varicella vaccination to adults without immunity; when there is no history of chickenpox or prior vaccination, administer 2 doses approximately 1 month apart.
Provide chikungunya vaccination to adults aged 18 years and older traveling to a country or territory with a chikungunya outbreak.
Consider live attenuated chikungunya vaccination for adults aged 18 years and older taking up residence or traveling for 6 months or longer to a country or territory without an outbreak but with elevated risk.Travel or residence of 6 months or more
Provide chikungunya vaccination to laboratory workers with potential exposure to chikungunya virus.

Diagnostic services performed for symptoms, abnormal findings from prior preventive or diagnostic studies, repeat testing at a shortened interval, or an individual outside the population addressed by the applicable recommendation or guideline are not covered under the preventive-care benefit. These services are processed under the applicable non-preventive medical benefit and may be subject to deductible, coinsurance, or copayment.

Service-Specific Coding and Eligibility Details

Abdominal aortic aneurysm screening

ServiceAbdominal aortic aneurysm screening

MethodUltrasonography

FrequencyOne time

Eligible populationMen aged 65-75 years who have ever smoked

Statin use for primary cardiovascular disease prevention

ServiceLow- to moderate-dose statin for primary cardiovascular disease prevention

AgeAdults aged 40-75 years

Documentation, Billing, and Processing Guidance

Billing Rule

Report Qualifying Services as Preventive

When a covered service is performed for preventive screening and is appropriately reported, bill it under the preventive care services benefit. Apply preventive reporting when the member has no relevant symptoms or abnormal findings, is within the recommended screening interval with normal findings, or has normal diagnostic results followed by a physician recommendation for future preventive screening at preventive intervals.

Document the screening purpose and applicable recommendation or interval.
Report the service as preventive only when the clinical circumstances support preventive screening.

Documentation Required

Document Diagnostic Rationale

Preventive Care Overview

Preventive care promotes health and supports the early detection or prevention of disease and injury rather than treating an established condition. This guide addresses preventive screenings, counseling, immunizations, wellness examinations, preventive medications, tobacco-cessation treatment, and services integral to a preventive benefit. Services performed to evaluate symptoms, abnormal findings, or an established condition are treated as diagnostic or therapeutic services instead of preventive care.

Key Policy Terms

Preventive care

PurposePromote health and support early detection or prevention of diseases and injuries

Not intended forTreating or curing diseases or injuries

ExamplesExaminations and screening tests tailored to age, health, and family history

Diagnostic service

PurposeEvaluate symptoms or abnormal prior findings

Follow-upIncludes shortened-interval follow-up or repeat testing after abnormalities

Population scopeIncludes services for a person outside the population addressed by the preventive recommendation

Policy Summary

PayerAmbetter Nevada

PolicyPreventive Care Guide

Policy CodePolicy N/A

Change TypeNo material change

Effective DateJanuary 1, 2026

Next Review DateN/A

Key ActionReport covered services as preventive when they are performed for preventive screening, the member has no symptoms or abnormal findings, and the service is within the recommended interval.

SourceLink

On This Page

Screen for syphilis during pregnancy and in asymptomatic nonpregnant adolescents and adults at increased risk.

Screen adults aged 18 years or older for unhealthy drug use by asking questions when accurate diagnosis, effective treatment, and appropriate care can be offered or referred.

Provide HIV risk assessment and prevention education beginning at age 13.

Adults who have never received Tdap receive one dose at any time, followed by Td or Tdap every 10 years.

Medical historyNo history of cardiovascular disease

Risk factorsAt least one cardiovascular disease risk factor, such as dyslipidemia, diabetes, hypertension, or smoking

10-year cardiovascular event risk10% or greater

High BMI intervention in children and adolescents

ServiceIntensive behavioral intervention for high BMI

Minimum age6 years or older

BMI criterionBMI greater than or equal to the 95th percentile for age and sex

Lung cancer screening

ServiceAnnual lung cancer screening with low-dose computed tomography

AgeAdults aged 50-80 years

Smoking historyAt least a 20 pack-year smoking history

Smoking statusCurrently smokes or quit within the past 15 years

Prediabetes and type 2 diabetes screening

ServicePrediabetes and type 2 diabetes screening

AgeAdults aged 35-70 years

Weight statusOverweight or obese

Visual impairment screening

ServiceVision screening to detect amblyopia or its risk factors

Eligible populationAll children aged 3-5 years

Minimum frequencyAt least once

Folic acid supplementation

ServiceFolic acid supplementation for prevention of neural tube defects

Daily dose0.4 to 0.8 mg (400 to 800 micrograms)

Eligible populationIndividuals planning to or who could become pregnant

Lung cancer screening eligibility

Screening methodLow-dose computed tomography (LDCT)

Age50-80 years

Smoking history20 pack-year smoking history

Smoking statusCurrently smokes or quit within the past 15 years

Prediabetes and type 2 diabetes screening

ScreeningPrediabetes and type 2 diabetes screening

Eligible ageAdults aged 35-70 years

Eligibility conditionOverweight or obese

Weight-loss behavioral intervention

ServiceIntensive multicomponent behavioral intervention for weight loss

BMI thresholdBMI of 30 or higher

PopulationAdults

Midlife obesity prevention counseling

ServiceIndividualized counseling to maintain weight or limit weight gain

AgeWomen aged 40-60 years

BMI range18.5-29.9 kg/m2

Counseling focusHealthy eating and physical activity to prevent obesity

Cervical cancer screening

PopulationAverage-risk women

Age range21-65 years

Ages 21-29Cervical cytology (Pap test) every 3 years

Ages 30-65Cytology and human papillomavirus testing every 5 years, or cytology alone every 3 years

Gestational diabetes screening

Preferred screening window24-28 weeks of gestation

General timingAfter 24 weeks of gestation

Earlier screeningBefore 24 weeks when risk factors for type 2 diabetes or gestational diabetes are present

Earlier timing targetIdeally at the first prenatal visit

Pediatric depression screening

ServiceDepression screening

PopulationChildren and adolescents

Age range12-21 years

FrequencyAt each recommended visit

Pediatric fluoride varnish

ServiceFluoride varnish for dental caries prevention

Eligible ageChildren ages 6 months to 5 years

Risk requirementHigh risk for dental caries

FrequencyEvery 3-6 months

Document the clinical reason for diagnostic services and process them under the applicable non-preventive medical benefit when the service is intended to evaluate a symptom, abnormal finding, or other diagnostic concern. Diagnostic services may be subject to the member's deductible, coinsurance, or copayment.

Record relevant symptoms, prior abnormal preventive or diagnostic results, and the reason for repeat or additional testing.
Document when testing is performed at a shortened interval or for a person outside the population covered by the preventive recommendation.

Documentation Required

Document Lung Cancer Screening Eligibility

For lung cancer screening with low-dose computed tomography, document the eligibility elements supporting annual preventive screening and the member's ability and willingness to undergo curative lung surgery.

Record age 50–80 years.
Record a smoking history of at least 20 pack-years.
Record current smoking status or, if the member quit, the quit date showing cessation within the past 15 years.
Discontinue screening once the member has not smoked for 15 years or develops a health problem that substantially limits life expectancy or the ability to undergo curative lung surgery.

Documentation Required

Document Drug-Use Screening and Follow-Up

For unhealthy drug-use screening in adults, document question-based screening and confirm that accurate diagnosis, effective treatment, and appropriate care are available directly or through referral. Screening means asking questions about unhealthy drug use, not testing biological specimens.

Record the screening questions or result and the member's age or applicable population.
Document available diagnostic and treatment follow-up, including referrals when needed.

Documentation Required

Document Risk Assessment and Referrals

Document the risk assessment, screening result, clinical judgment, and any intervention or referral for STI counseling, intimate partner or domestic violence, and anxiety services. For anxiety screening, optimal intervals are unknown, so use and record clinical judgment regarding frequency.

For STI counseling, record sexual history and risk factors and provide or refer for directed behavioral counseling when indicated.
For intimate partner or domestic violence screening, document screening of adolescent and adult women at least annually when applicable, plus intervention or referral when needed.
For anxiety screening, document the result and clinical judgment supporting the screening interval, including for pregnant or postpartum women.
Record referrals for counseling, education, harm-reduction strategies, supportive services, or other appropriate intervention.

Documentation Required

Document Postpartum Diabetes Surveillance

For women with a history of gestational diabetes who are not currently pregnant and have not been diagnosed with type 2 diabetes, document postpartum diabetes surveillance, testing, results, and the follow-up plan.

Record the gestational-diabetes history and postpartum timing; perform initial testing ideally within the first year and as early as 4–6 weeks postpartum.
If not screened in the first year or if the initial postpartum result is negative, plan screening at least every 3 years for a minimum of 10 years after pregnancy.
For a positive early-postpartum result, repeat testing at least 6 months postpartum to confirm diabetes, regardless of the initial test type.
Repeat testing after hemoglobin A1c performed in the first 6 months postpartum regardless of whether the result was positive or negative.

Unsupported block type: documentation

Billing Rule

Use the Diagnostic Benefit When Appropriate

When a covered service is performed for diagnostic rather than preventive purposes, identify and process it under the applicable non-preventive medical benefit instead of the preventive care benefit.

Use the non-preventive benefit for evaluation of symptoms, abnormal findings, shortened-interval repeat studies, or services outside the applicable preventive population.
Apply the member's applicable cost share when the service is processed under the non-preventive medical benefit.

Billing Rule

Apply Network and Billing Classification Rules

Apply the no-cost-share preventive benefit when a qualifying preventive service is furnished by an in-network Ambetter Health provider and is appropriately billed as preventive. Preventive coverage is generally 100% of the contracted amount without deductible, coinsurance, or copayment; services billed or performed for diagnostic purposes follow the applicable medical benefit.

Use appropriate preventive billing and coding that reflect the screening purpose and qualifying circumstances.
Apply the richest coverage when applicable recommendations address the same benefit differently, and account for additional state-required preventive benefits.

Note

Use Reasonable Medical Management for Unspecified Details

When a preventive recommendation does not specify frequency, method, treatment, or setting, apply reasonable medical management to determine coverage limitations and operational requirements.

Reasonable medical management may include precertification, concurrent review, claim review, or similar practices.
Use the member's plan terms and established management practices to determine the covered frequency, method, treatment, or setting.

Benefit classificationProcessed under the applicable non-preventive medical benefit

USPSTF A/B recommendation

SourceCurrent recommendations of the United States Preventive Services Task Force

Evidence standardEvidence-based items or services

RatingIn-effect rating of A or B

ACIP recommendation

SourceCenters for Disease Control and Prevention

CommitteeAdvisory Committee on Immunization Practices

ScopeRoutine-use immunizations for children, adolescents, and adults

StatusIn-effect recommendation

HRSA preventive guidelines

Women's guidanceHRSA-supported preventive-care and screening guidance for women

Pediatric guidanceHRSA-supported Bright Futures guidance for infants, children, and adolescents

SupportGuidelines supported by the Health Resources and Services Administration

LDCT

TermLDCT

Full nameLow-dose computed tomography

UseAnnual lung cancer screening

Unhealthy drug use screening

Screening methodAsking questions about unhealthy drug use

Not includedTesting biological specimens

Adult populationAdults aged 18 years or older

Care requirementImplement when accurate diagnosis, effective treatment, and appropriate care can be offered or referred

Intimate partner and domestic violence

Physical violenceIncluded

Sexual violence and stalkingIncluded

Psychological aggressionIncludes coercion

Other included conductReproductive coercion, neglect, and threats of violence or abuse

Diabetes screening after pregnancy

PopulationWomen with a history of gestational diabetes mellitus

TimingAfter pregnancy; initial testing ideally within the first year postpartum and as early as 4-6 weeks postpartum

Pregnancy statusNot currently pregnant

Prior diagnosisNo previous diagnosis of type 2 diabetes

Single lifetime RSV dose

RecommendationA single RSV vaccine dose for adults aged 50-59 years at increased risk of severe RSV disease

Lifetime statusOne dose over the lifetime

Repeat vaccinationNot recommended for people who have already received RSV vaccination

Elevated chikungunya travel risk

VaccineLive attenuated chikungunya vaccine

Minimum ageAdults aged 18 years and older

Travel or residence durationTaking up residence or traveling for 6 months or longer

DestinationA country or territory without an outbreak but with elevated chikungunya risk