What is Preventive Care?

Why is preventive health care important?

Preventive care helps detect or prevent serious diseases and health problems before they can become major. Annual check-ups, some immunizations, and flu shots, as well as certain tests and screenings, are a few examples of preventive care. This may also be called routine care.

How much does preventive care cost?

Most health plans are required by law to cover eligible preventive care services at 100%. This includes health insurance plans you get through your employer as well as those you may buy on your own through the Health Insurance Marketplace. This means you can get access to preventive health services at no additional cost to you. 

Your doctor must also be in-network in order to be fully covered. Your health insurance company should have a provider directory to see which doctors are in your plan's network. Check with your health plan details to find out which preventive services are covered. 

Not all preventive care services are covered and different plans may cover different things. For example, immunizations for travel are usually not covered. See your plan materials for a complete list of covered preventive care services.

What are preventive care services?

Below are examples of preventive care services and health screenings, as well as examples of non-preventive care. Make sure to review the details of your health plan to understand what services are covered at 100% and at what ages and frequency.

Preventive Health Care

Annual check-up or wellness exam

This is when your Primary Care Provider (PCP) checks all areas of your well-being—both physical and mental health. Annual check-ups are covered once a year and can help detect any health concerns early before they become major medical problems.

Well-baby and well-child appointments

These are regular health check-ups for babies and children. They include weight and physical growth checks, vaccines (if needed), and development assessment. These typically occur at roughly the following ages:

• 1 to 7 days
• 1 month
• 2 months
• 4 months
• 6 months
• 9 months
• 12 months
• 15 months
• 18 months
• 2 years
• 2.5 years
• Annually starting at 3 years

Flu shot

Flu shots are typically covered 100% every year under most health plans. These vaccines help protect you from certain strains of the flu virus as well as reduce hospitalizations.

Other vaccinations

Immunizations for certain diseases like chickenpox, HPV, measles, mumps, rubella, polio, and more are covered 100%. These are usually administered during childhood and include boosters as needed.

Preventive Health Screenings

Mammogram

Mammograms are routine X-rays of breast tissue to check for any signs of breast cancer or other abnormalities. Mammograms are usually recommended every year starting at age 40 but may be recommended sooner if you have certain risk factors.¹

Colonoscopy

This is a screening for colon and colorectal cancer. It's typically done every 10 years starting at age 45 unless you have other risk factors.² There are also at-home tests available for colorectal cancer screening which are covered at $0. If an at-home test is positive or abnormal, a colonoscopy will be needed. This is considered part of the screening and is covered as preventive care.

Other cancer screenings

These may include prostate, lung, and cervical cancer screenings.

Screenings for health conditions

These may include diabetes, depression, and osteoporosis.

Non-preventive Health Care

• Diagnostic tests and screenings: These are not routine tests and screenings. For example, if your radiologist finds something on your lung cancer screening and wants another, that would be considered diagnostic testing and not typically covered as preventive care.
• Additional primary care visits: Most health plans will cover you for one annual check-up with your doctor. Other visits during the same calendar year will likely not be covered as preventive. For example, let’s say you have flu symptoms and need to see your doctor virtually or in person—that’s not a covered preventive care visit.
• Specialist visits: Visits to a specialist (gastroenterologist, orthopedist, neurologist, podiatrist, etc.) for a particular problem are not covered as preventive care.
• Alternative therapies: Therapies such as chiropractic, massage, acupuncture, and other alternative health services are not considered preventive care.

What are the benefits of preventive care?

Preventive care is intended to help you stay as healthy as possible. Regularly scheduled visits and tests allow your doctor to identify any medical problems before they can become major.

Benefits of preventive care include the following:

• Most preventive care at no additional cost to you as part of your health coverage.
• Early detection of medical problems, illnesses, and diseases helps your doctor provide proactive care and treatment.
• Routine care can help you stay focused on your own health goals.

What’s the difference between preventive care and diagnostic care?

Diagnostic care is related to services in which your provider is looking for something specific, often based on the results of a preventive test or screening.

For example, a radiologist may ask for a follow-up mammogram for a patient. This follow-up is to check for something that may have been detected during the preventive or routine mammogram. The follow-up mammogram is diagnostic, and not covered as preventive care.

How do you know what preventive care you need and when?

Your PCP can help you coordinate what tests and vaccines are right for you. They may consider things like:

• Your age
• Your health history
• Your family history
• Your current health status

See a complete list of preventive care services.

Preventive care is often covered 100% by your health plan and offers many benefits, both in cost and health. If you have questions about what’s covered and not covered, or when you should have certain tests done, make sure to ask your doctor or your health insurance company.