Preventive Care: What's Free and What's Not

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Thanks to the Affordable Care Act, health insurers in the U.S. have to cover preventive health care without requiring you to pay a deductible, copayment, or coinsurance.

So, what exactly counts as preventive care? Here’s the list of preventive care services for adults that, if recommended for you by your physician, must be provided free of cost-sharing. Children have a different list.

Recommended cancer prevention measures:

  • Colorectal cancer related: for those over 50 years old, including screening colonoscopies, removal of polyps discovered during a screening colonoscopy, and anesthesia services required to perform the screening colonoscopy
  • Breast cancer related: including screening mammograms every 1-2 years for women over 40, BRCA genetic testing and counseling for women at high risk, and breast cancer chemoprevention counseling for women at high risk
  • Cervical cancer related: screening for sexually active women; human papillomavirus DNA testing once every 3 years for women over 30
  • Lung cancer related: screening for smokers or those who’ve quit smoking within the last 15 years and are between the ages of 55 and 80

Recommended infectious disease prevention measures:

  • Hepatitis C screening one time for anyone born 1945-1965 and for any adult at high risk
  • Hepatitis B screening for pregnant women at their first prenatal visit
  • HIV screening for anyone between ages 15-65, sexually active women, and for others at high risk
  • Syphilis screening for adults at high risk and all pregnant women
  • Chlamydia screening for young women and women at high risk
  • Gonorrhea screening for women at high risk
  • Sexually transmitted infection prevention counseling for adults at increased risk
  • Routine immunizations for adults as recommended by age for
    • Hepatitis A.
    • Hepatitis B.
    • Herpes Zoster(shingles).
    • Human Papillomavirus.
    • Influenza (flu).
    • Measles, Mumps, Rubella.
    • Meningococcal.
    • Pneumococcal.
    • Tetanus, Diphtheria, Pertussis (lock-jaw and whooping cough).
    • Varicella (chicken pox).

Obesity screening and counseling.

Diet counseling for adults at high risk for chronic disease.

Recommended cardiovascular disease-related preventive measures:

  • Cholesterol screening for high risk adults and adults of certain ages
  • Blood pressure screening
  • Diabetes type 2 screening for adults with high blood pressure
  • Abdominal Aortic Aneurysm screening one time for men who have smoked
  • Aspirin when prescribed for cardiovascular disease prevention at certain ages

Recommended substance abuse prevention measures:

  • Alcohol misuse screening and counseling
  • Tobacco use screening and cessation intervention for tobacco users

Depression screening.

Domestic violence and interpersonal violence screening and counseling for all women.

Osteoporosis screening for women over 60 based on risk factors.

Well-woman visits for women under 65.

Contraception for women with reproductive capacity as prescribed by a health care provider. Doesn’t include abortifacient drugs, doesn’t apply to health plans sponsored by exempt religious employers. Learn more about the specifics no-cost-sharing contraception in “Free Birth Control—Maximize Your Affordable Care Act Benefit.”

Preventive services for pregnant or nursing women:

  • Anemia screening
  • Breastfeeding support and counseling including supplies
  • Folic acid supplements for pregnant women and those who may become pregnant
  • Gestational diabetes screening at 24 and 28 weeks gestation and those at high risk
  • Hepatitis B screening at first prenatal visit
  • Rh incompatibility screening for all pregnant women and follow up screening if at increased risk
  • Expanded tobacco counseling
  • Urinary tract or other infection screening
  • Syphilis screening

Why Preventive Care Isn’t Free

If your health insurance is a grandfathered health plan, it’s allowed to charge cost-sharing for preventive care. Since grandfathered health plans lose their grandfathered status if they make substantial changes to the plan, they’re becoming less and less common as time passes. Your health plan literature will tell you if your health plan is grandfathered. Alternatively, you can call the customer service number on your health insurance card or check with your employee benefits department.

If you have a managed care health plan that uses a provider network, your health plan is allowed to charge cost-sharing for preventive care you get from an out-of-network provider. If you don’t want to pay for preventive care, use an in-network provider.

If a preventive service isn’t:

then it generally won’t be offered without cost-sharing.

Preventive Care Isn’t Really Free

Although your health plan must pay for preventive health services without charging you a deductible, copay, or coinsurance, this doesn’t really mean those services are free to you. Your insurer takes the cost of preventive care services into account when it sets your premium rates each year.

Although you don’t pay cost-sharing charges when you receive preventive care, the cost of those services is wrapped into the cost of your health insurance. This means, whether or not you choose to get the recommended preventive care, you’re paying for it through the cost of your health insurance premiums anyway.

Sources:
Preventive Health Services for Adults, HealthCare.gov. Accessed 5/27/2015.
Affordable Care Act Implementation FAQs - Set 12, The Center for Consumer Information & Insurance Oversight, Centers for Medicare & Medicaid Services. Accessed 5/27/2015.
Affordable Care Act Implementation FAQs - Set 18, The Center for Consumer Information & Insurance Oversight, Centers for Medicare & Medicaid Services. Accessed 5/27/2015.
FAQs about Affordable Care Act Implementation (Part XXVI), Employee Benefits Security Administration, United States Department of Labor. Accessed 5/28/2015.

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