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What’s Preventive Healthcare Insurance and What’s Covered Under These Plans?

What’s preventive health insurance?

Preventive health insurance is exactly what it sounds like: a plan that covers care received in order to prevent the onset of illness. Historically, most plans have covered preventive care at varying levels. After the passing of the Affordable Care Act, all plans are now required to cover preventive doctor’s visits and exams at zero cost to the consumer. Insurance companies are mandated by law to provide this level of benefit for any service that’s determined to be preventive, such as your annual physical exam. Be sure to check your benefits summary, though. Many plans, such as PPO plans, provide 100 percent coverage for preventive care, but require you to use an in-network provider.

Keep reading to learn more about what’s covered under preventive healthcare benefits.

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What’s covered?

What’s covered under preventive healthcare services?

Preventive care can be categorized into three buckets:

  • for adults
  • for women
  • for children

Each category has its own list of preventive services. In an ACA-compliant plan, the following services must be covered at 100 percent. Be aware that fee schedules may change if you’re enrolled in a or plan, as those plans aren’t subject to the same ACA requirements.

Preventive care for adults

An adult is anyone over the age of 18.

Screenings

  • abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
  • alcohol misuse screening
  • blood pressure screening
  • cholesterol screening for adults of certain ages or at higher risk for high cholesterol
  • colorectal cancer screening for adults over age 50
  • depression screening
  • type 2 diabetes screening for adults with high blood pressure
  • hepatitis B screening for people at high risk
  • hepatitis C screening for adults at increased risk, and one-time screening for people born between 1945 and 1965
  • HIV screening for anyone ages 15-65, and other ages if at increased risk
  • lung cancer screening for adults ages 55-80 who are heavy smokers or who quit smoking in the past 15 years
  • obesity screening
  • syphilis screening for adults at higher risk

Medications

  • aspirin to prevent cardiovascular disease for men and women of certain ages

Immunizations

Immunization doses, recommended ages, and recommended populations vary, so check with your insurance provider to understand your coverage for the following immunizations.

  • hepatitis A
  • hepatitis B
  • human papillomavirus (HPV)
  • influenza (flu shot)

Counseling

  • alcohol misuse counseling
  • diet counseling for adults at higher risk for chronic disease
  • obesity counseling
  • sexually transmitted infection (STI) prevention counseling for adults at higher risk
  • smoking cessation interventions for tobacco users

Preventive care for women

Preventative care for women falls into two buckets, care for all women, and care for women who are pregnant or may become pregnant.

All women Pregnant women or women who may become pregnant
breast cancer genetic test counseling (BRCA) for women at higher risk anemia screening on a routine basis
breast cancer mammography screenings every 1 to 2 years for women over age 40 breast-feeding comprehensive support and counseling from trained providers
breast cancer chemoprevention counseling for women at higher risk for breast cancer breast-feeding supplies for pregnant and nursing women
cervical cancer screening for sexually active women Food and Drug Administration (FDA)-approved contraceptive methods, sterilization procedures, and education and counseling. (This does not apply to health plans sponsored by certain exempt “religious employers.”)
chlamydia infection screening for younger women and other women at higher risk folic acid supplements
domestic and interpersonal violence screening and counseling for all women gestational diabetes screening for women 24-28 weeks pregnant, or those at high risk of developing gestational diabetes
gonorrhea screening for women at higher risk hepatitis B screening at first prenatal visit
HIV screening and counseling for sexually active women Rh incompatibility screening for all pregnant women and follow-up testing for women at higher risk
human papillomavirus (HPV) DNA test every 3 years for women with normal cytology results who are 30 or older syphilis screening
osteoporosis screening for women over age 60, depending on risk factors expanded tobacco intervention and counseling for pregnant women who use tobacco
STI counseling for sexually active women urinary tract or other infection screening
syphilis screening for women at an increased risk
tobacco use screening and interventions
well-woman visits to get recommended services for women under age 65
 

Preventive care for children

A child is anyone under the age of 18.

Screenings

  • autism screening at ages 18 and 24 months
  • behavioral assessments
  • blood pressure screening
  • cervical dysplasia screening for sexually active females
  • depression screening for adolescents
  • developmental screening for children under age 3
  • alcohol and drug use assessment for adolescents
  • dyslipidemia screening for children between ages 1-17 at higher risk for lipid disorders
  • hearing screening for all newborns
  • height, weight, and body mass index (BMI) measurements
  • hematocrit or hemoglobin screening
  • hemoglobinopathies or sickle cell screening for newborns
  • hepatitis B screening for adolescents at high risk
  • HIV screening for adolescents at higher risk
  • hypothyroidism screening for newborns
  • lead screening for children at risk of exposure
  • obesity screening
  • phenylketonuria (PKU) screening for newborns
  • oral health risk assessment for children ages 0-10
  • STI screening for adolescents at higher risk
  • tuberculin testing for children at higher risk of tuberculosis
  • vision screening

Medications

  • fluoride chemoprevention supplements for children without fluoride in their water source
  • gonorrhea-preventive medication for the eyes of all newborns
  • iron supplements for children ages 6-12 months at risk for anemia

Immunizations

Immunization doses, recommended ages, and recommended populations vary, so check with your provider before your child receives one of the following vaccines to determine your coverage:

  • diphtheria, tetanus, pertussis (whooping cough)
  • hepatitis A
  • hepatitis B
  • human papillomavirus (HPV)
  • influenza (flu shot)

Additional services covered

  • medical history for all children throughout development ages
  • obesity counseling
  • STI-prevention counseling for adolescents at higher risk

Wellness programs

Another preventive service that most insurance companies cover are wellness programs. Many consumers either don’t utilize or aren’t aware of this benefit. Wellness programs are designed to improve and promote health and fitness. They’re usually offered through an employer or employer-sponsored plan, but insurers also offer them directly to individual enrollees. These programs often offer incentives and rewards to participants for achieving specific milestones toward a healthier lifestyle. For example, the carrier may offer you a $50 gift card for losing 5-10 pounds, exercising more during the week, or undergoing biometric screening.

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Choosing a provider

Choosing a provider for preventive healthcare coverage

According to the (NCQA), here are some of the top health plans in the country in terms of preventive care:

Children and adolescents Women Cancer Screening
Capital District Physicians' Health Plan (HMO)
Harvard Pilgrim Health Care (PPO)
Kaiser (HMO)
Tufts Benefit Administrators (PPO)
Anthem BCBS (HMO/PPO)
 
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Takeaway

Takeaway

Preventive services must be offered to you and your dependents free of charge as long as you’re receiving care within your plan’s network of health providers and facilities. Preventive services are covered at this level of benefit regardless of the plan type or insurance carrier as long as your plan is ACA compliant. If you’re currently enrolled in a grandfathered or grandmothered plan through a group policy, you may be subject to copays or coinsurance. It’s always a good idea to consult your broker, HR person, or insurance provider if you’re unsure if a specific service is covered. For more information as well as updates to the list of covered preventive services, visit .

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Q&A

Well-visit Q&A

  • I’m a healthy adult. How often should I have a well-visit?
  • You should see your doctor yearly for a well-visit. The doctor will do a complete physical and, depending on your medical history, may draw blood for lab work and recommend screenings. Women should also get the recommended well-woman screening.

    - Debra Sullivan, PhD, MSN, RN, CNE, COI
  • Answers represent the opinions of our medical experts. All content is strictly informational and should not be considered medical advice.
Article resources
  • Grandfathered Health Plan. (n.d.). Retrieved from
  • Norris, L. (2016, March 22). Like your grandmothered health plan? Retrieved from
  • NCQA health insurance plan ratings 2015-2016 – Summary report (private). (n.d.). Retrieved from
  • Preventative health services. (n.d.). Retrieved from
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