What is Preventative Care and What Services Are Covered?

Preventative care is routine care to help people maintain their good health and prevent serious medical conditions and illnesses. Most preventative care services are covered in full by insurance companies, but it’s important to understand exactly what is and is not included. Here’s what you need to know. 

What is Preventative Care?

Preventative care (also known as routine care) helps detect and prevent serious diseases and medical issues. Some of the common components of preventative care are:

Annual checkups: It’s recommended that most adults visit their primary care provider (PCP) once per year for a checkup when your doctor will examine you and perform routine tests such as checking blood pressure. If you have any concerns or questions about your health, you can discuss them with your doctor at your annual checkup. Your doctor can also recommend further diagnostics if they are concerned about something that comes up during your visit.

Flu shots: An annual flu shot is recommended for most people to help protect them from serious illness during flu season. You can receive your flu shot at your doctor’s office or a participating pharmacy. Most health insurance plans offer complete coverage for flu shots.

Additional vaccinations: Other vaccinations are also considered to be preventative care. Most vaccinations are administered during childhood, but some vaccinations require occasional boosters. 

Mammograms: Mammograms are a major part of preventative care for women. These are routine X-rays of breast tissue to check for signs of abnormalities or cancer. It’s recommended that women start getting mammograms every year after age 45, though some women ages 55 and older may opt to get a mammogram every other year. Women can also get mammograms before age 45 if a doctor recommends it. Men and nonbinary individuals may also be eligible for mammograms, especially if they have a genetic mutation that increases their risk of developing breast cancer. 

Colonoscopy: Colonoscopy is a routine part of preventative care for everyone over age 50. The procedure screens for colon cancer and, in most cases, is recommended for colonoscopy every five to 10 years. Some doctors may recommend colonoscopies before age 50 or more frequently, especially if the patient has a family history of colorectal cancer or polyps. 

What is Diagnostic Care?

Diagnostic care is different from preventative care because it includes healthcare services and procedures that involve investigating and treating a health issue. Diagnostic care may happen as a result of something that was discovered during a preventative care visit or procedure. 

Tests and screenings: If your doctor is concerned about a possible health condition, they may recommend diagnostic tests and screenings. For example, if you tell your doctor at your annual checkup that you’re concerned about your digestive health, they may recommend a colonoscopy. While colonoscopies are a routine part of preventative health care, if your doctor recommends it for a nonroutine reason like this, it is considered diagnostic care, not preventative care. 

Extra office visits: Most health insurance plans will only cover one visit to your PCP each year for your annual checkup. If you visit your doctor other times during the year, it is not considered part of your preventative care. Common reasons to visit your doctor outside of your annual checkup include treatment for flulike symptoms or an injury such as a sprained ankle. 

Specialist visits: Preventative care typically only includes visits to your PCP. If you visit a specialist such as a gastroenterologist or an orthopedist, this falls outside of the scope of preventative care.

Alternative therapies: Though some alternative health services may be thought of as preventative care measures, they typically aren’t included in the insurance company’s definition of preventative care. Some alternative therapies may include acupuncture, chiropractic services and massages.

The PSA blood test: The prostate-specific antigen (PSA) test is primarily used to screen for prostate cancer. Some insurance companies may include this in their preventative care benefits, but many consider it to be a diagnostic care procedure.

The Benefits of Preventative Care

If you’re healthy, you might be wondering why you should bother going to the doctor for preventative care. As much as you might not like taking time out of your busy schedule to go to the doctor, there’s no denying the benefits of preventative care. 

Low to no cost: Most health insurance plans are legally required to cover 100% of eligible preventative care expenses, such as an annual checkup. 

Early detection: Regular preventative care can help you and your doctor detect signs of serious health problems early. By detecting issues early, they can be easier to treat and reduce the impact on your overall health. 

Reaching health goals: Establishing and maintaining a relationship with your PCP will enable you to get answers to your health-related questions. It also helps your PCP get to know you and your health goals so they can help you reach them. For example, if you want to lose weight or improve your cardio fitness, your PCP can help you manage your progress and provide suggestions when needed.

Is All Preventative Care Covered?

Most health plans are required to cover preventative services such as vaccinations, annual checkups and routine screening tests. Every plan offered through the Health Insurance Marketplace falls under these requirements, and some plans outside of the Marketplace may have the same requirements. 

There are exceptions to be aware of. For example, your health insurance plan might be required to cover your preventative health services, but it may have requirements for you as well. Most health insurance plans have a network of doctors and providers who accept their plan. If you visit a doctor for preventative care but the doctor does not accept your insurance plan, your preventative care may not be free. In these cases, your insurance may only cover a portion of the expenses, or you may be responsible for the entire bill.

Compare Health Insurance

Finding the right health insurance plan can be a major headache. That’s why Benzinga regularly researches and reviews the top healthcare providers to help you pick the plan that will give you the best care. Take a look at some of the top health insurance providers for your preventative care needs.

Who Needs Preventative Care?

Whether it’s a child or an adult, everyone benefits from preventative care. That’s why most health insurance providers are required to cover 100% of eligible preventative healthcare services. Benzinga’s guide to health insurance can help you navigate plans to find the right one for you.

Frequently Asked Questions