What Is Preventative Healthcare, and What Is Typically Free on Private Insurance

Did you know that only 8% of Americans undergo routine preventive screenings? This indicates that a very low number of people seek preventative healthcare, which is something that needs to change! As is famously said, prevention is better than cure, making preventative healthcare an essential aspect of maintaining good health. 

Preventative healthcare aims to identify and prevent potential health problems and improve health outcomes. Today, we will discuss everything you need to know about preventative healthcare and what is typically free with private insurance.

What Is Preventative Healthcare and Health Insurance?

According to experts, preventative healthcare deals with the prevention of illnesses. This helps lower the burden of diseases (and associated risk factors). To that end, preventative health insurance refers to a healthcare plan that covers care received by a person to prevent the onset of an illness. Most private insurance plans cover preventive care to varying degrees.

After the Affordable Care Act passed, all private insurance plans now have to cover preventive doctor's visits and annual physical exams at zero cost to the individual.

Pro Tip: When browsing through the insurance plan, make sure to check the benefits summary. Even though plans (think: PPO plans) offer 100% coverage for preventive care, they require you only to visit in-network providers.

What Is Free with Private Insurance?

Let's now take a look at what is free with private insurance. The first thing to note is that preventative care is categorized into three buckets:

• For Adults
• For Women
• For Children

Here are the preventative services that should be offered for free under your private insurance plan:

Evidence-Based Screenings and Counseling

Insurers must cover evidence-based services for adults that have a rating of "A" or "B," which refers to services that have a substantial or moderate net health benefit. The services that will be covered (without cost sharing) include screenings for:

• Depression
• Diabetes
• Obesity
• Various types of cancers
• Sexually Transmitted Infections (STIs)
• Prenatal tests
• Medications that can help prevent HIV.
• Heart disease
• Counseling for drug and tobacco use, healthy eating, and other common health concerns

Routine Immunizations

Health plans should also offer coverage (without cost-sharing) for adults and children for immunizations, such as:

• Influenza
• Meningitis
• Tetanus
• HPV
• Hepatitis A and B
• Measles
• Mumps
• Rubella
• Varicella
• COVID-19 (including updated boosters) for people enrolled in non-grandfathered plans 

Preventive Services for Women

Current recommendations include:

• Well-woman visits
• All FDA-approved, granted, or cleared contraceptives and related services.
• Breastfeeding support and supplies
• Broader screening and counseling for a range of conditions, including intimate partner violence, urinary incontinence, anxiety, STIs, and HIV

A Summary of Selected Preventive Services for Adults Covered by Non-Grandfathered Private Plans (without Cost Sharing)

Cancer

• BRCA-related cancer – risk assessment, genetic counseling, and genetic testing (USPSTF ) (women at high risk)
• Breast cancer screening, mammography (USPSTF & HRSA) (women 40+)
• Breast cancer – medications for risk reduction (USPSTF) (women at high risk)
• Cervical Cancer Screening – human papillomavirus testing (HRSA) (women 30–65 with normal pap results)
• Cervical cancer screening – pap testing (USPSTF) (women 21+ with cervix)
• Colorectal cancer screening (USPSTF) (adults 45 to 75)
• Lung cancer screening (USPSTF) (adults 50 to 80 with history of smoking)
• Skin Cancer Prevention – behavioral counseling (USPSTF) (parents of young children and young adults with fair skin)

Chronic Conditions

• Depression screening (USPSTF) (adults when follow up support is available)
• Abdominal aortic aneurysm screening (USPSTF) (men between 65–75 who have ever smoked)
• Hepatitis B infection screening (USPSTF) (adults at high risk for infection)
• Hypertension (high blood pressure) screening (USPSTF) (adults 18–79)
• Hepatitis C infection screening (USPSTF) (adults 18-79)
• Latent tuberculosis infection screening (USPSTF) (adults at increased risk)
• Osteoporosis screening (USPSTF) (all women 65+; high risk women <60)
• Prediabetes & type 2 diabetes screening (USPSTF) (adults 35–70 who are overweight or obese)
• Weight loss to prevent obesity-related morbidity and mortality in adults: behavioral interventions (USPSTF) (adults with BMI of ≥30)
• Statin use for prevention of cardiovascular disease (USPSTF) (adults 40–75)

Health Promotion

• Healthy diet and physical activity for cardiovascular disease (CVD): behavioral counseling (USPSTF) (adults with risk factors)
• Fall prevention in older adults (USPSTF) (community-dwelling adults 65+)
• Interventions for tobacco smoking cessation in adults (USPSTF) (all adults)
• Obesity prevention in midlife women (HRSA) (women 40–60 with normal or overweight BMI)
• Intimate partner violence screening and counseling (USPSTF & HRSA) (all women)
• Anxiety screening (HRSA) (adolescent and adult women)
• Unhealthy drug use screening (USPSTF) (adolescents and adults)
• Unhealthy alcohol use in adolescents and adults: screening and behavioral counseling and interventions (USPSTF) (adults 18+, including pregnant women)
• Well woman visit (HRSA) (women)
• Urinary incontinence screening (HRSA) (women)

Reproductive Health

• Contraceptive services and counseling (HRSA) (everyone with reproductive capacity)
• Chlamydia and gonorrhea screening (USPSTF) (sexually active women ≤24; older women at risk)
• HIV infection screening (USPSTF & HRSA) (adolescents and adults 15+)
• STI counseling (USPSTF & HRSA) (adults at high risk; sexually active adolescents; all sexually active women)
• Preexposure prophylaxis (PrEP) for HIV prevention (USPSTF) (persons at high risk for HIV)
• Syphilis screening (USPSTF) (adolescents and adults at increased risk)

Pregnancy

• Breastfeeding services and supplies (HRSA)
• Asymptomatic bacteriuria in adults: screening (USPSTF)
• Breastfeeding: primary care interventions (USPSTF)
• Folic acid supplements to prevent neural tube defects (USPSTF)
• Depression screening (USPSTF)
• Gestational diabetes screening (USPSTF & HRSA)
• Healthy weight and weight gain in pregnancy: behavioral counseling interventions (USPSTF)
• Hepatitis B screening (USPSTF)
• Syphilis screening (USPSTF)
• Screening for diabetes mellitus after pregnancy (HRSA)
• Rh(D) incompatibility: screening (USPSTF)
• Preeclampsia screening & preventive medicine (USPSTF)
• Perinatal depression: preventive interventions (USPSTF)
• Interventions for tobacco smoking cessation (USPSTF)
• HIV screening (USPSTF)

Immunizations

• Haemophiles influenzae Type B (ACIP) (adults 18+ with risk factors)
• COVID-19 (ACIP) (all adults)
• Hepatitis A (ACIP) (adults with risk factors)
• HPV (ACIP) (adults 18–26 not previously vaccinated; at risk men 22– 26)
• Hepatitis B (ACIP) (adults with risk factors)
• Influenza (ACIP) (yearly)
• Meningococcal (ACIP) (adults 18+ with risk factors)
• Measles, mumps and rubella (ACIP) (adults 18– 49; 50+ with risk factors)
• Zoster (shingles) (ACIP) (adults 50+)
• Varicella (ACIP) (adults who have never had chickenpox or have never been vaccinated)
• Td booster, Tdap (ACIP) (all adults)
• Pneumococcal (ACIP) (adults 19– 64 with risk factors; adults 65+)

Preventive Services for Children and Youth 

Health plans must include provisions for improving the health and well-being of infants, children, and adolescents. The preventive services covered for children and adolescents include:

• Well-child visits
• Immunization and screening services
• Behavioral and developmental assessments
• Fluoride supplements
• Screening for autism
• Vision impairment
• Lipid disorders
• Tuberculosis
• Certain genetic diseases

A Summary of Selected Preventive Services for Children Covered by Non-Grandfathered Private Plans (without Cost Sharing)

Infectious Diseases and Chronic Conditions

• Bilirubin concentration screening (BF/AAP) for newborns
• Blood pressure screening (BF/AAP) for all children
• Blood screening (BF/AAP) for newborns
• Dyslipidemia screening (BF/AAP) for all children
• Gonorrhea preventive medication (USPSTF) for newborns
• Hematocrit or hemoglobin screening (BF/AAP) for all children
• Hypothyroidism screening (BF/AAP) for newborns
• Lead screening (BF/AAP) for children at risk
• Phenylketonuria screening (USPSTF) for newborns
• Tuberculin testing (BF/AAP) for all children

Child Development

• Autism screening (BF/AAP) for children at 18 and 24 months
• Behavioral assessments (BF/AAP) for all children
• Depression screening (USPSTF and BF/AAP) for adolescents
• Developmental screening (BF/AAP) for children under 3 years of age
• Height, weight, and body mass index (BMI) measurements (BF/AAP) of all children
• Anxiety screening (USPSTF) children and adolescents

Sexual Health (Adolescents)

• Hepatitis B screening (USPSTF and BF/AAP) for adolescents
• HIV screening (USPSTF and BF/AAP) for adolescents at risk
• PrEP HIV prevention medication (USPSTF) for adolescents at risk
• Sexually transmitted infection (STI) prevention counseling and screening (BF/AAP) for adolescents at risk

Health Promotion

• Alcohol, tobacco, and drug use assessments (USPSTF and BF/AAP) for adolescents
• Fluoride supplements (BF/AAP) for children without fluoride in their water source
• Fluoride varnish (BF/AAP) for all children
• Hearing screening for newborns and regular screenings (BF/AAP) for all children
• Obesity screening and counseling (USPSTF) for all children
• Oral health risk assessment (BF/AAP) for young children
• Vision screening (USPSTF and BF/AAP) for young children
• Well-baby and well-child visits (BF/AAP) for all children
• Skin cancer prevention counseling (USPSTF) for children and adolescents

Immunizations Recommended by ACIP

• Chickenpox
• Diphtheria, tetanus, and pertussis (DTaP)
• Hepatitis A
• Hepatitis B
• Mumps
• Human Papillomavirus (HPV)
• Inactivated Poliovirus
• Influenza (flu shot)
• Measles
• Meningococcal
• COVID-19
• Rotavirus
• Rubella
• Pneumococcal

Coverage Rules and Clarifications to Remember

• Patients may have to pay for the office visit if your primary reason for the visit is not the preventive service.
• If you are enrolled in a grandfathered or grand mothered plan, the fee schedules may change, as those plans aren't subject to ACA requirements.
• Suppose an out-of-network provider performs the preventive service (when an in-network provider is available to perform the service). In that case, insurers may charge you for the office visit and the preventive service. However, if an out-of-network provider is used because no in-network provider can provide the service, then cost-sharing does not apply.
• If treatment is given as the result of a recommended preventive service but is not the recommended preventive service itself, cost-sharing may be charged. 

Preventative healthcare is the foundation for staying healthy and happy. You can use preventative services free of charge as long as the care you are receiving is within your plan's network of health providers. Make sure to check with your insurance provider to see if a specific service is covered under your policy. 

Looking for a medical facility that offers a variety of preventative healthcare services? The Rocky Vista Health Center is here to take care of all aspects of your health and overall well-being. We have the resources to address all your medical needs, from internal medicine and primary care to osteopathic medical services and telemedicine services. Contact us today.