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Know Your Preventive Care Coverage

Learn how your plan discounts or covers preventive services

Written by: Andrew Hall.

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Key Takeaways

  • Preventive care helps you stay healthy and can lower your overall healthcare costs.

  • The screenings and tests considered to be preventive care can help identify risk for diseases before they exist.

  • The goal of preventive services is to promote health and well-being and prevent disease and/or disability.

  • Basic preventive services must be provided by insurance companies.

What is Preventive Care?

Preventive care consists of healthcare services to keep you healthy, including check-ups, patient counseling, and screenings to prevent disease and other health-related problems. In 2010, the Patient Protection and Affordable Care Act (ACA), required insurance companies to cover a set of preventive services at no cost to the policyholder.

How Does Your Plan Determine Preventive Services?

Preventive health care refers to measures taken to prevent disease and injuries. Most preventive care screenings are covered under all health insurance plans at 100% when administered by an in-network doctor. Your doctor may include a preventive service as part of an office visit. This means that your plan could require you to pay some of the costs for your visit through a copay or coinsurance if the preventive services are not the primary reason for the visit.

Additionally, certain preventive services are limited to people within certain risk categories or age groups. For example, colorectal cancer screenings are considered preventive care for adults ages 50-75. This means that if you are 25 and not at risk for colorectal cancer, the screening is not covered as a preventive service.

How Do Preventive Services Work for Plan Beneficiaries?

Adults, women, and children all have different types of services offered to them under preventive services. What is considered a preventive service? Below are some examples of typical preventive services offered for adults, women, and children. For a full list of preventive care services for adults, women and children, visit HealthCare.gov [1] or contact your health insurance company.

Adults:

  • Blood pressure screening
  • Cholesterol screening
  • Colorectal screening
  • HIV screening
  • Immunizations

Women:

  • Anemia screening
  • Breastfeeding support
  • Contraception
  • Preeclampsia screening

Children:

  • Autism screening
  • Blood pressure screening
  • Immunizations
  • Vision screenings

FAQs

What’s the difference between diagnostic services and preventive services?

Diagnostic services help your provider diagnose your illness and decide on your treatment. They may even involve some tests used as preventive services. But, these services are not preventive if you get them as part of a visit to:

  • Diagnose a new condition
  • Monitor a condition you already have
  • Treat an illness or injury

What if I receive preventive and non-preventive services in the same office visit?

You can have preventive and non-preventive services in the same office visit. For example, you may visit your doctor for a Pap screening to check for cervical cancer (preventive care). In the same visit, you may wish to discuss a health concern (non-preventive care). Your office visit benefit may apply to the non-preventive part of your visit.

What’s Next?