Preventive services refers to preventive care. Insurers now must provide many of these services at no cost.
Preventive care save lives and improves ones health by identifying illnesses earlier, managing them more effectively, and treating them before they develop into something more serious.
Screenings & Immunizations
If you have a new health insurance plan beginning on or after September 23, 2010, the plan generally must provide coverage for a range of preventive health services without requiring any cost sharing (copay or coinsurance).
This requirement applies to all private health insurance plans, including individual, small group, large group, and self-insured plans. However, grandfathered plans are exempt from this requirement.
Preventive services must be covered without having to pay a copayment or coinsurance or meet your deductible.
♦ This applies only when these services are delivered by a network provider.
• Under the Trump administration many in the GOP called for a scaling back of Preventive Service requirements saying they were "too generous."
With Democrats in control of the House only rule changes could be made by the Health and Human Services (HHS) department. This resulted in a small chipping away of some benefits; most of which the Biden administration rescinded.
Preventive services for all adults, women, and children
Private health insurance plans generally must provide coverage for a range of preventive health services without requiring any patient cost sharing.
♦ Many providers are failing to properly code a lot of these procedures as “preventive.” And many insurers are incorrectly applying charges to people’s deductible. The burden is on you to carefully inspect all Explanation of Benefits (EOBs) and challenge your insurer to review suspect claims.
There are 3 sets of free preventive services. Select the links below to see a list of covered services for each group:
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease for men and women of certain ages
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults over 50
- Depression screening
- Diabetes (Type 2) screening for adults with high blood pressure
- Diet counseling for adults at higher risk for chronic disease
- Falls prevention (with exercise or physical therapy and vitamin D use) for adults 65 years and over, living in a community setting
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults at increased risk, and one time for everyone born 1945 – 1965
- HIV screening for everyone ages 15 to 65, and other ages at increased risk
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adults at high risk for getting HIV through sex or injection drug use
Immunization vaccines for adults — doses, recommended ages, and recommended populations vary:
- Lung cancer screening for adults 55 - 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Syphilis screening for adults at higher risk
- Tobacco Use screening for all adults and cessation interventions for tobacco users
- Statin preventive medication for adults 40 to 75 at high risk
- Tuberculosis screening for certain adults without symptoms at high risk
- Anemia screening on a routine basis
- Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Birth control: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.” Learn more about contraceptive coverage.
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Preeclampsia prevention and screening for pregnant women with high blood pressure
- Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings every 1 to 2 years for women over 40
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening Pap test every 3 years for women 21 to 65
- Human Papillomavirus (HPV) DNA test every 5 years for women 30 to 65 who don't want a Pap smear every 3 years
- Diabetes screening for women with a history of gestational diabetes who aren’t currently pregnant and who haven’t been diagnosed with type 2 diabetes before
- Chlamydia infection screening for younger women and other women at higher risk
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for sexually active women
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative women at high risk for getting HIV through sex or injection drug use
- Bone density (Osteoporosis) screening for women over age 60 depending on risk factors
- Rh incompatibility screening follow-up testing for women at higher risk
- Sexually transmitted infections counseling for sexually active women
- Syphilis screening for women at increased risk
- Tobacco use screening and interventions
- Urinary incontinence screening for women yearly
- Well-woman visits to get recommended services for women under 65
- Alcohol and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
- Bilirubin concentration screening for newborns
- Blood pressure screening for children ages: 0 to 11 months, 1 to 4 years , 5 to 10 years, 11 to 14 years, 15 to 17 years
- Blood screening for newborns
- Depression screening for adolescents
- Developmental screening for children under age 3
- Dyslipidemia screening for children at higher risk of lipid disorders ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
- Fluoride chemoprevention supplements for children without fluoride in their water source
- Flouride varnish for all infants and children as soon as teeth are present
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns
- Height, weight and body mass index (BMI) measurements for children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at high risk, including adolescents from countries with 2% or more Hepatitis B prevalence, and U.S.-born adolescents not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence: 11 – 17 years.
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- PrEP (pre-exposure prophylaxis) HIV prevention medication for HIV-negative adolescents at high risk for getting HIV through sex or injection drug use
- Immunization vaccines for children from birth to age 18 — doses, recommended ages, and recommended populations vary:
- Iron supplements for children ages 6 to 12 months at risk for anemia
- Lead screening for children at risk of exposure (WebMD: Lead Blood Test: What to Expect)
- Maternal depression screening for mothers of infants at 1,2,4, and 6-month visits
- Medical history for all children throughout development ages: 0 to 11 months, 1 to 4 years , 5 to 10 years , 11 to 14 years , 15 to 17 years
- Obesity screening and counseling
- Oral health risk assessment for young children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
- Vision screening for all children
- Well-baby and well-child visits
Know before you go
A routine physical or colonoscopy would be covered without cost sharing. But there will be cases where the doctor may perform services that go beyond routine, for these you may have to pay part of the cost in the form of a copay or coinsurance.
Example 1: You have a physical exam and the doctor charges for a second office visit because he or she advised you on a specific health issue. The charge may be warranted because of additional time spent explaining the issue.
But more often than not the charge is simply a form of up charging the office is using to increase revenue. They know your physical costs you nothing so you are not likely to complain about an office copay.
Example 2: You have a physical exam and the doctor orders blood tests for uric acid to monitor your gout condition. Or a test for Vitamin D levels because you have a history of low Vitamin D levels.
These are not typical preventive tests but are used to help treat or monitor a specific health condition. Most plans will balk at covering these tests at 100% but if your doctor codes the reason as preventive and you complain a little there is a good chance your insurance company will agree to cover them.
Example 3: Colonoscopies done as routine screening are covered at 100%.
But colonoscopies done to evaluate a specific problem may be classified by the doctor as a diagnostic procedure, which are not covered at 100%.
You may go in for a screening colonoscopy but then the doctor finds and removes a few polyps. A pathologist would bill you for evaluating the polyps.
Depending upon your plan your screening could easily turn into a diagnostic colonoscopy and not a preventive one.
♦ Colonoscopies often get coded and processed as diagnostic when they were actually preventive.
You need to read the Explanation of Benefits (EOB) and ask questions. If the colonoscopy comes back clean then it was "preventive" and should be paid at 100%. Don't be afraid to push for a claims review.
♦ Colonoscopies are routinely performed in surgical centers or outpatient facilities. It is important to make sure the facility you will use is in your plan’s network along with the anesthesiologist that will be attending you at the facility.
Don’t assume because the doctor scheduled you at the facility that everyone is in your network. Check first, because there have been many cases where the doctor’s services for the colonoscopy were covered at 100% but then the patient was hit with a large bill from the facility or the anesthesiologist because one or both were not in-network.