Preventive Services: Coverage and Costs
June 25, 2020
You’re probably used to going to a doctor when you feel sick. But to prevent illness, it also can be important to seek healthcare when you feel well. With preventive services, such as vaccines and cancer screenings, you can avoid certain diseases and catch others in their early stages, before they have a chance to cause much harm.
Preventive services don’t need to be costly. Federal law requires many health insurance plans to provide certain screenings and other services for free. Even if some services aren’t required, some insurers cover them because they make good business sense. Preventing disease often costs insurers less than treating it.
Types of Preventive Services
Types of preventive services include:
- Disease screenings. These are tests to see if you have a disease before you have felt or reported symptoms. When a disease is caught at an early stage, treatment can often be more effective. Whether you should have a certain screening test depends on your risk factors. Those are circumstances that increase the chance that you may get the disease. For example, when you reach age 50, you’re at greater risk for colorectal cancer. In that case, the recommendation is that you get screened for it when you turn 50, and on a regular basis afterward.
- Reducing your risk factors. There are some risk factors you can’t control, such as your age and family history. But you can control others, such as smoking, which puts you at greater risk for many diseases. If you smoke, a program to help you quit smoking can lower your risk for those diseases. Being overweight or obese also raises your risk for several diseases. If your weight is greater than normal for your height, you may benefit from dieting and exercise counseling. (Reducing risk factors may overlap with wellness services. See Wellness Programs: Coverage for Promoting Healthy Living in this issue.)
- Vaccinations. A vaccine, or shot, gives you immunity to a certain disease, so you have less chance of getting it. For example, an annual flu shot lowers your risk of getting the flu for the coming flu season. Based on your age and other risk factors, it may be recommended that you get certain vaccines.
Want more information on preventive services that may be right for you and your family? Talk to your doctor and visit MyHealthFinder.
Free Preventive Services
Under the Affordable Care Act (ACA) of 2010, most health plans must cover certain preventive services at no cost to you. You don’t have to pay a copay or coinsurance for those services and your deductible doesn’t apply. Those are forms of cost sharing by which you normally pay for part of your healthcare.
To prevent any surprises in getting your preventive services, make note of these points:
- Stay in network. The preventive services are free only when you get them from a doctor or other provider in your health plan’s network. Those are the providers who have agreed to accept your plan’s contracted rate as payment in full for their services. Make sure the provider who gives you the service is in your plan’s network.
- Related services may not be free. Even though a particular screening or other service is free, related services may not be. For example, suppose you get a colorectal cancer screening for free. You still may have to pay at your usual cost-sharing rates for the anesthesia services provided with the screening. Check with your insurer in advance to find out what is and isn’t covered for free. Also, if a problem is found and treated at the time of the screening test (e.g., a biopsy is performed), it’s no longer considered screening but diagnostic and therapeutic. In such a situation, the procedure may be subject to deductibles, coinsurance and other out-of-pocket costs.
- Some older plans may be exempt from the law. The plans that have to provide these free services include new health plans created after the ACA was signed. They also include plans that have changed their coverage since then. Older plans that have stayed the same since the law was signed are considered “grandfathered.” There are probably few such plans now. But, to be sure yours isn’t one of them, check your plan documents or ask your employer or insurance company representative.
- Not every preventive service is free. The law doesn’t require health plans to cover every kind of preventive service for free. For example, plans don’t have to cover an annual physical exam or checkup for everyone for free. Even so, many insurers do cover an annual checkup for free. Talk to your doctor about whether you’ll need to get one and what cost, if any, would apply.
The ACA breaks into three categories the types of preventive services that must be covered for free. The categories are all adults, women and children. For full details, see HealthCare.gov’s information here. This is a brief sampling of the services:
- For all adults. Based on age and other risk factors, services include screening for a number of diseases, such as colorectal cancer, depression and type 2 diabetes. Services also include blood pressure, cholesterol and obesity screening; vaccines; and tobacco use screening with an intervention to help tobacco users quit.
- For women. Some services are specifically for pregnant women or women who may become pregnant, such as breastfeeding support and counseling, birth control (with some exceptions) and folic acid supplements. Others are for all women, depending on age and other risk factors, such as annual well-woman visits, breast cancer mammographies and screenings for osteoporosis.
- For children. Some services are meant to be given throughout childhood, including behavioral assessments and vision screening. Others are intended for specific age groups, such as alcohol and drug use assessments for adolescents, or for other specific risk factors. Standard childhood vaccines are covered, such as those for measles, diphtheria and polio.
Your health plan may offer more preventive services for free than just the minimum required by law. Check with your insurer or doctor to see which other services may be covered for free.