Whats Preventive Healthcare Insurance and Whats Covered Under These Plans?

Curated by Claudia Shannon / Research Scientist / ishonest

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 grandfathered or grandmothered plan, as those plans aren’t subject to the same ACA requirements.

Preventive care for adults
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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

Immunizations

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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.

Preventive care for children

A child is anyone under the age of 18.

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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)
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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.

Choosing a provider for preventive healthcare coverage

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

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 Healthcare.gov.

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