In this article
- 1 Preventive Care
- 2 What Counts as Preventive Care?
- 3 What Does Not Count as Preventive Care?
- 4 Who Determines what Counts as Preventive Care?
- 5 What is the Cost of Preventive Care?
- 6 Is There a Limit to How Much Preventive Care I Can Receive?
- 7 Is There a Lifetime Dollar Limit on Preventive Care?
- 8 Takeaway
Preventive Care
What is it, what's included, & how much will it cost?
There was a time when preventive care wasn’t a thing. Doctors were more focused on making you feel better rather than keeping you healthy.
With the advent of the 2010 Affordable Care Act and the essential health benefits, there was a shift that forced doctors to focus on the quality of the care the gave and not the quantity of patients they saw. This, coupled with what is called ‘value-based payments,’ has led to insurance companies offering a lot of services and test, completely free of charge to the insured, with the idea that by being proactive about your health now, you will be healthier in the future.
What Counts as Preventive Care?
Preventive care is any healthcare practice that helps prevent disease and improves overall health. Preventive care is important because it cane help people avoid chronic conditions later in their lives and detect health problems early, before they become more difficult to treat.
Most health plans are required by law to cover eligible preventive services at 100%. This means that there are no out-of-pocket cost for these services, so long you see a doctor or clinic that is in the plan’s network, even if you haven’t met your annual deductible yet.
Common preventive care services
Regular checkups; your annual physical exam is a type of preventive care. Your doctors will help identify and treat health issues before they worsen by checking your general appearance, reviewing your health history, checking your vital signs, and performing a few test.
Preventive screenings for most cancers, blood pressure, cholesterol, heart disease, and diabetes.
Obesity screening and counseling
Depression screening (mental health is still your health!)
Immunizations & vaccinations; there are different immunizations given depending on your age, but everyone is covered, from birth, in one way or another.
Vision screening and oral health assessment for children
Domestic violence screening and counseling for women
Education & counseling so that you understand better about what healthy lifestyle choices look like for you. These can also include discussions about alcohol use and safe drinking.
Depending on if you are enrolled in Medicare, Medicaid, or an ACA compliant health plan, where you receive your care and what is offered may vary. Additionally, some people enrolled in Medicare Part C Advantage plans may have additional benefits not offered to other Medicare beneficiaries. This is due to how Part C plans practice what is called ‘managed care.’
Always make sure to read your plan’s Summary of Benefits to understand exactly what your plan does and does not cover in addition to the mandated services and procedures. A full list of the mandated services can be found here.
What Does Not Count as Preventive Care?
Preventive care happens before a problem is found. So, some services may or may not be considered and billed as preventive depending on your health situation. For example, a colonoscopy is considered preventive, even if tissue is removed. However, if you are diagnosed with colon cancer and tissue needs to be removed (the same way as it would be for a colonoscopy), you will need to pay cost sharing.
Other non-preventive care examples include primary care visits if they are related to a specific health need, such as a cold or the flu. Appointments with specialist may not be covered depending on your insurance. Most diagnostic test and screenings are also not covered as preventive.
Who Determines what Counts as Preventive Care?
There are three different groups that make recommendations about preventive care; the US Preventive Services Task Force, the Health Resources and Services Administration, and the Advisory Committee on Immunization Practices.
Any service or procedure must be recommended by at least one of these groups to be considered preventive care.
The guidelines that these groups put out do change over time, so the list of covered preventive services also change from time to time. For example, COVID vaccines were added in December of 2020.
What is the Cost of Preventive Care?
There is no upfront cost to you. You will not pay a copay or coinsurance, even if you haven’t met your deductible yet.
But that doesn’t mean that the service is free. Your insurance company already factored the cost of this service into what you pay each month.
By not taking advantage of these services, you’re both allowing the insurance companies to hang on to the money they ear marked for you, and you’re increasing the risk of a larger health issue further down the road.
Sometimes preventive services will be grouped together with non-preventive that may result in a charge. For example, if your provider does a cholesterol test and a complete blood count test, the cholesterol test will be covered but you may pay for the CBC, even though the CBC can be used to detect certain diseases.
Other times, a preventive screening may lead to a diagnostic, which is not covered without cost sharing. For example, preventive mammograms are covered, but if a lump is found your provider may request further test that are not covered.
Is There a Limit to How Much Preventive Care I Can Receive?
Yes. Limits are applied based on the recommendations and guidelines by the same organizations that determine what counts as preventive. Your age, gender, and medical history can also play a role.
Normally, you are limited to a set number of each service per policy year. This means that you could not have two annual check-ups. Like always though, read through your summary of benefits for the exact details about your plan.
Is There a Lifetime Dollar Limit on Preventive Care?
Nope. Insurance companies cannot cap your benefits to a dollar amount; this includes preventive care.
Takeaway
There is almost zero downside to making use of any of these services. You are already paying for them each month through your premiums, and putting any of these test or procedures off until later simply increases the risk of a bigger health issue later in life.
An ounce of prevention is worth a pound of cure. Your health is your life. Take care of it.
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