All health plans must cover some basic services to help prevent illnesses and maintain your health and well-being.
Yearly physicals and immunizations are common examples of preventive care
Preventive care is typically free, but you may end up paying out of pocket if you see an out-of-network provider
Preventive care is any service that helps prevent illness and maintain your health and well-being. You may see preventive care referred to as preventative care. Annual checkups and immunizations are common preventive services, which can uncover signs of potential health problems before they get worse and lead to chronic diseases. You can typically schedule a preventive care visit with your primary care doctor, but some preventive benefits may require a specialist visit.
Preventive care is one of the 10 essential health benefits that must be included in Affordable Care Act-compliant plans. (An ACA-compliant plan, or Obamacare plan, is any plan purchased through the health insurance marketplace.) Health insurers are typically required to provide these services at no extra cost, but there are some instances when you might have to pay, like when you see a doctor that is outside the terms of your plan.
Preventive care includes diagnostic testing, physical exams, and immunizations (shots). You may need to meet certain qualifications (like being a certain age) for some preventive services to be covered by your health insurance, and there may be restrictions as to how often you can get these services. For instance, a physical exam and flu shot are common preventive care benefits that are typically covered only once a year.
Preventive care services also vary based on whether you are an adult or child. Health insurers also provide extra preventive care services for women, like mammograms.
Here is a list of specific preventive services that must be offered at no cost by health providers. You can find more details on preventive care guidelines on healthcare.gov or check the details of your plan.
The following immunizations and vaccines are also covered:
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There are also services aimed at women's health, which are available to pregnant women, women who may become pregnant, and mothers of newborn children.
The following preventive care services are available for children (under age 18). Some screenings have further restrictions regarding age.
In most cases it is not necessary for you to have reached your deductible before the services are covered by your health insurance plan. You shouldn’t have to pay copays or coinsurance for preventative services either, but health insurance providers are still allowed to charge you in certain situations according to the terms of your health plan so make sure you know the details.
You might pay for preventive services if you seek care from an out-of-network provider that isn't covered by your health insurance, so it’s important to know what type of plan you have and what providers are in your network. For example, HMO plans don’t offer any out-of-network coverage while PPO plans usually offer some.
Learn about the differences between HMO, PPO, EPO, POS plans.
Similarly, even if you have a preventative care visit with an in-network doctor, the lab that processes your screening test or blood work could be out-of-network, which would make you responsible for the costs. Ask your doctor beforehand to find out as much information as you can about what other contractors might be involved.
Another reason a preventative service might not be free is if it wasn't the primary reason for seeing the doctor. For example, if you see your primary care doctor because of an illness (which is considered diagnostic care) and end up getting an unrelated preventive screening or immunization, you'll still need to pay your usual office visit copay. Likewise, if you go in for a preventive care service, like a basic flu shot, and end up getting tests for something else, like bronchitis, or other illness-related diagnostic care, you may need to pay for a full appointment. To avoid this from happening, make sure your preventive care visit is separate from your primary care visit.
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Elissa is a personal finance editor at Policygenius in New York City. She writes about estate planning, mortgages, and occasionally health insurance. In the past she has written about film and music.
Policygenius’ editorial content is not written by an insurance agent. It’s intended for informational purposes and should not be considered legal or financial advice. Consult a professional to learn what financial products are right for you.
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