Health Insurance and Preventive Care
Here's everything you need to know about how different health plans cover--or don't cover--various forms of preventative health care.
First, the good news: no matter what kind of health insurance you have, it likely covers at least some forms of preventive care.
Now for the bad news: not all plans cover this care as fully as others.
Before we get to how different types of health insurance--from employer-sponsored to Obamacare to Medicare and more--treat these services, though, let's make sure we're on the same page as to what constitutes preventive (or preventative) care.
According to the U.S. Centers for Disease Control and Prevention (CDC), preventive care generally refers to services such as lab tests, shots, screenings, check-ups, and counseling sessions that aim to prevent illnesses, diseases, and other health problems. It also refers to services that detect illness at an early stage when treatment is likely to be most successful.
Here are some examples of common preventive care services:
- Blood pressure, cholesterol, and diabetes tests
- Mammograms, colonoscopies, and other cancer screenings
- Screenings for sexually transmitted diseases (STDs) or sexually transmitted infections (STIs)
- Vaccinations for polio, meningitis, measles, and many other diseases
- Flu and pneumonia shots
Insurers often consider regular check-ups and physicals preventive care, too. The same is true of counseling for issues like reducing alcohol use, quitting smoking, losing weight, and treating depression.
As you might guess, that's just the tip of the iceberg. Plus, other services specific to children and women--especially pregnant women--constitute preventive care as well.
Why do health insurance plans cover preventive care services? The short answer to this question is preventive care helps policyholders--people--become healthy or stay healthy.
"For most people, having a regular screening physical exam and routine medical lab tests is a good starting point to help identify small health problems before they become bigger ones," said Chirag Shah MD, co-founder of Accesa Labs.
Insurers like that, of course, and for a number of reasons. One is that it saves them money.
Preventive care also saves lives. In fact, the CDC says that if all Americans received recommended preventive care, it would save over 100,000 lives each year.
This is because, as suggested earlier, these tests, screenings, and interventions help identify illnesses and diseases early. They also help doctors and other care providers manage illnesses and diseases and keep them from becoming too complicated or debilitating.
Private Health Plans and Preventative Care Coverage
Do you have some kind of private health insurance plan? You're in luck. "Under the Affordable Care Act, insurance companies are required to cover preventative health care services," says Sal Raichbach, Chief of Clinical Compliance at Ambrosia Treatment Center.
And not only that, but they have to cover those services without any patient cost-sharing.
What is "private" health insurance? If yours is an individual, small group, or large group plan, it's private. (Employers offer small and large group plans, by the way, so if you get your health insurance through your job, it's likely one of these.) The same is true of self-insured plans in which employers contract administrative services to a third-party payer.
As for what "cost-sharing" means, in this case it refers to the deductibles, copayments, or co-insurance fees that usually accompany doctor or hospital visits or other attempts to receive medical care.
In other words, if you have a private health insurance policy, it has to cover the preventive services listed below without requiring any copays, deductibles, or co-insurance.
The only exceptions to all of the above are the few remaining “grandfathered” health plans. These plans existed before March 23, 2010, which is when President Barack Obama signed the ACA into law. To maintain their grandfathered status, they can't make significant changes to their coverage.
Assuming yours isn't a grandfathered plan, it has to cover these preventive services:
1. Evidence-based screenings and counseling
A few examples:
- screenings for depression, diabetes, cholesterol, and obesity
- screenings for various cancers
- screenings for HIV, STDs, and STIs
- counseling for drug and tobacco use and other common health concerns
2. Routine immunizations
Some common immunizations covered here: hepatitis A and B, HPV, influenza (flu), and meningitis. Private health plans also usually cover measles, mumps, rubella, and tetanus.
3. Preventative services for children and youth
This includes some of the services described above as well as:
- behavioral and developmental assessments
- iron and fluoride supplements
- screenings for autism, vision impairment, tuberculosis, and certain genetic diseases
4. Preventative services for women
Again, many of the services mentioned earlier are covered here plus:
- well-woman visits
- FDA-approved contraceptives and related services
- broader screening and counseling for STDs, STIs, and HIV
- breastfeeding support and supplies
- domestic violence screenings
Obamacare Plans and Preventative Care
As could be expected, policies sold through the federal health insurance marketplace or state exchanges also cover a wide range of preventive care.
Like the plans discussed above, Obamacare plans have to cover these services without charging policyholders copays or coinsurance. This is true even if you've yet to reach your yearly deductible.
Keep in mind, though, that these plans only cover preventive care delivered by an in-network doctor or other provider. If you, your spouse, or dependent children receive preventive care outside your network, you'll probably be responsible for copayments or co-insurance costs.
Some of the services marketplace and exchange plans tend to cover:
- Aspirin use to prevent cardiovascular disease
- Blood pressure, cholesterol, and diabetes screenings
- Colorectal and lung cancer screenings
- Hepatitis B and C screenings
- HIV and STD or STI screenings
- Hepatitis A and B, HPV, flu, measles, mumps, tetanus, varicella (chickenpox), and other vaccines
- Alcohol misuse, depression, diet, obesity, and tobacco use screenings and counseling
Note: Obamacare health plans only cover some of these services if you're over a certain age or if you're considered a high risk.
For example, these policies only cover colorectal cancer screenings if you're over 50. They only cover lung cancer screenings if you're between the ages of 55 and 80 and you're either a heavy smoker or have quit in the last 15 years. And they only cover diabetes screenings if you have high blood pressure.
To learn more about preventive care covered by Obamacare plans, go to healthcare.gov.
Obamacare plans cover many types of preventive care for pregnant women or women who may become pregnant, too, including:
- Anemia screenings
- Breastfeeding support and counseling
- FDA-approved contraceptives
- Gestational diabetes screenings
- Gonorrhea screenings
And they cover all women who seek these services:
- Breast and cervical cancer screenings
- Osteoporosis screenings
- Domestic and interpersonal violence screenings and counseling
- Well-woman visits
Again, these plans cover more kinds of preventive care than are listed here. Also, some of this coverage depends on a policyholder being above a certain age or having a certain risk level.
Visit healthcare.gov for more information on how Obamacare health plans cover preventive care for women.
Unsurprisingly, health insurance bought via the federal marketplace or one of the state exchanges also covers many forms of preventive care for children.
Some of the most common (see the full list here):
- Autism, developmental, hearing, and vision screenings
- Behavioral assessments
- Hepatitis A and B, HPV, chickenpox, flu, whooping cough, and other vaccines
Medicare and Preventive Care Coverage
Original Medicare plans also cover many forms of preventive care. Specifically, Medicare Part B, often called "medical insurance," covers services like:
- Bone mass measurements
- Cardiovascular disease screenings
- Breast, cervical, and vaginal cancer screenings
- Colorectal cancer screenings
- Prostate cancer screenings
- Diabetes screenings
- Glaucoma tests
- Flu, hepatitis B, and pneumococcal shots
Medicare Part B also covers the cost of a “Welcome to Medicare” preventive visit and yearly "wellness" visits.
The one-time “Welcome to Medicare” visit, which has to be scheduled within the first year of Medicare Part B enrollment, includes a review of your medical and health history. It also includes certain screenings and tests, all of which are detailed and explained at medicare.gov.
As for the yearly wellness visits Medicare covers, they help you develop or update a "personalized prevention" plan. The purpose of these plans is to prevent disease and disability based on your individual health and risk factors.
Medicare covers one wellness visit every 12 months, although you can't schedule your first one until after you've been enrolled in Part B for a full year.
You pay nothing for either of these visits if your doctor or care provider accepts assignment. That's also true for the tests, screenings, shots, and other services listed earlier.
There are times when you may have to pay coinsurance, or when your Medicare Part B deductible may apply, however. One example is if your physician or provider performs tests or services that aren't preventive during the same visit.
Also, your physician or provider may suggest you have certain tests, screenings, or shots done more frequently than Medicare covers. If that happens, you might have to pay some or all of the costs associated with those services.
To avoid being surprised by an unexpected bill, talk with your doctor and insurer before you agree to anything. In particular, ask if Medicare will pay for the recommended services.
That's good advice no matter what kind of health insurance you have, actually. Whether your plan is sponsored by an employer, was bought through the federal marketplace (or a state exchange), or is tied to Medicare, make sure it covers any preventive care you're considering before you have it done.
Preventive vs Diagnostic Care
Don't confuse preventive and diagnostic care. This is a relatively common mistake that can leave you paying more money than you expect for health care. Diagnostic care, as the name suggests, comes into play after a health issue arises. "It is healthcare that diagnoses or monitors a problem that the patient already has," says Raichbach. "So, if you go to the doctor because you’re having persistent headaches, that would fall under the category of diagnostic care.”
So, does insurance cover it? It depends. “Insurance companies are free to share the cost of these procedures with the patient through co-pays, deductibles, and co-insurance,” says Raichbach. It's not like preventive care, which insurers are legally obligated to cover.
Preventive and diagnostic care sometimes overlap, which can lead to some billing difficulties. "Patients can be charged for preventive care and diagnostic care in the same visit. For example, if a patient complains of headaches during a routine check-up, they will be billed for the diagnostic work,” says Raichbach. “So, even though that patient came to the doctor to get a preventative wellness check that is fully covered, they will be billed for the diagnostic portion of that visit."
What does this mean? Study your policy and find out what is and isn't covered before you commit to any care. That'll help you avoid any sticker shock when your bill comes.
Frequently Asked Questions
Q: What is preventive care?
A: Preventive care is the term used to describe lab tests, shots, screenings, check-ups, and counseling sessions that aim to detect or prevent illnesses, diseases, and other health problems.
Q: Why does health insurance cover preventive care?
A: There are a number of reasons most health plans cover these costs. An important one is preventive care helps people become and stay healthy. That means fewer trips to the doctor, fewer hospital visits, and fewer prescription drugs--all of which saves your insurer a lot of money.
Q: Do Medicare Advantage plans cover preventive care?
A: According to medicare.gov, "Medicare Advantage plans must cover all of the services that Original Medicare covers." So, whatever Medicare Advantage plan you buy should not charge you for preventive care services that are free for Original Medicare enrollees.
One notable exception: if an out-of-network provider performs those services, you'll likely have to pay for some or all of the resulting bill.
To learn more, read our article about about Medicare Advantage policies.
Q: Do Medigap or MedSup plans cover preventive care?
A: First, a little primer on MedSup and Medigap policies. These also are called Medicare supplemental insurance plans and they do what you'd expect them to do: they help pay for some of what Original Medicare doesn’t cover.
The thing is, Original Medicare fully covers the costs tied to most forms of preventive care. Still, Medigap or MedSup plans do lend a hand here now and then. For instance, your Medigap or MedSup plan should pay any co-insurance costs associated with preventive care you receive.
By the way, check out our Medigap and MedSup FAQ for more information about those plans. Or read this article: "When Does it Make Sense to Get a Medicare Supplement Plan?"
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