What Is Preventive Care and Does My Health Insurance Cover the Cost?


What Is Preventive Care- In the past, different plans offered varying levels of coverage for preventive care. However, thanks to the Affordable Care Act, all plans are now required to cover preventive doctor’s visits and exams at absolutely no cost to you, the consumer.

What Is Preventive Care? It’s a health insurance plan that focuses on providing care to prevent the onset of illness.

By law, insurance companies must provide this level of benefit for any service considered preventive, like your annual physical exam. However, it’s important to review your benefits summary because certain plans, such as PPO plans, offer 100 percent coverage for preventive care but only if you choose an in-network provider.


Now, let’s delve deeper and explore the specifics of what falls under preventive healthcare benefits.

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What’s Covered Under Preventive Healthcare Services?

Preventive care encompasses three main categories: adults, women, and children. Each category has its own set of services, and it’s important to understand what is covered under an ACA-compliant plan. However, keep in mind that fee schedules may vary for grandfathered or grandmothered plans, which don’t adhere to the same ACA requirements.

Preventive Care for Adults

As an adult, defined as anyone over the age of 18, you have access to a range of preventive services. These services include screenings for conditions such as abdominal aortic aneurysm, alcohol misuse, blood pressure, cholesterol, colorectal cancer, depression, type 2 diabetes, hepatitis B and C, HIV, lung cancer, obesity, and syphilis.


Certain medications like aspirin for cardiovascular disease prevention and immunizations for diseases like hepatitis A and B are covered. Counseling services are also available, addressing alcohol misuse, diet, obesity, sexually transmitted infections, and smoking cessation.

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Preventive Care for Women

Women’s preventive care can be divided into two categories: care for all women and care for pregnant women or those who may become pregnant. Services provided for all women include breast cancer genetic test counseling, mammography screenings, cervical cancer screenings, chlamydia and gonorrhea screenings, HIV screenings, HPV tests, osteoporosis screenings, counseling for domestic violence, and more.

Pregnant women or those planning pregnancy can receive additional services like anemia screenings, breastfeeding support and supplies, gestational diabetes screenings, and Rh incompatibility screenings, among others.


Preventive Care for Children

Children, defined as those under the age of 18, also benefit from preventive care services. These include screenings for autism, behavioral assessments, blood pressure, cervical dysplasia, depression, developmental milestones, hearing, height and weight measurements, lead exposure, obesity, oral health, STIs, tuberculosis risk, and vision.

Medications such as fluoride supplements, iron supplements, and preventive eye ointment for newborns are covered. Immunizations for diseases like diphtheria, tetanus, pertussis, hepatitis A and B, HPV, and influenza are also included.

Services encompass medical history documentation, obesity counseling, and STI-prevention counseling for adolescents at higher risk.

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Wellness Programs

Apart from the specific services mentioned above, most insurance companies offer wellness programs that focus on improving and promoting health and fitness.

These programs, commonly available through employers or directly from insurers, often provide incentives and rewards for achieving health-related goals.

Incentives may include gift cards, discounts, or other rewards for milestones such as weight loss, increased exercise, or participation in biometric screenings.

Understanding the scope of preventive care services ensures that you can take full advantage of the coverage provided by your insurance plan. Stay proactive in maintaining your health and well-being by utilizing these covered services and wellness programs available to you.

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Choosing the Right Provider for Preventive Healthcare Coverage

When it comes to preventive care, selecting the right provider is crucial. Here are some of the top health plans in the country recognized by the National Committee for Quality Assurance (NCQA) for their excellence in preventive care:

For Children and Adolescents:

  • Capital District Physicians’ Health Plan (HMO)
  • Harvard Pilgrim Health Care (PPO)
  • Tufts Benefit Administrators (PPO)

For Women:

  • Harvard Pilgrim Health Care (PPO)
  • Tufts Benefit Administrators (PPO)

Cancer Screening:

  • Capital District Physicians’ Health Plan (HMO)
  • Harvard Pilgrim Health Care (PPO)
  • Tufts Benefit Administrators (PPO)

It’s important to note that preventive services should be provided to you and your dependents free of charge if you receive care within your plan’s network of health providers and facilities. These services are covered at no cost regardless of the type of plan or insurance carrier, as long as your plan is ACA compliant. 

If you have a grandfathered or grandmothered plan through a group policy, you may be subject to copays or coinsurance. To ensure coverage for a specific service, it’s advisable to consult your broker, HR representative, or insurance provider.

For more detailed information and updates on the list of covered preventive services, you can visit Healthcare.gov. Making informed decisions about your preventive care provider is essential for maintaining your health and well-being.


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