Preventive and Wellness Care under the Affordable Care Act

By Lisa Yagoda, Nicole Duritz, Joan Friedman

Copyright © 2014 AARP. All rights reserved.

Under the Affordable Care Act (ACA), all new health plans sold to individuals and small groups, whether through the Health Insurance Marketplace or not, must provide certain types of coverage.

Many people have important preventive and wellness benefits because of the ACA — with no deductibles and copayments.

The ACA provides for an annual well-woman visit for adult women under age 65 so that they and their doctors can determine what preventive services may be needed.

All plans offered in the Marketplace, as well as any individual and small group insurance plans that aren’t grandfathered per the ACA, must also provide important preventive services at no additional cost to you — even if your plan has a deductible that you haven’t yet met.

Although the ACA encourages prevention by removing your costs for some services, it isn’t a perfect solution. You may be responsible for costs related to a service — for example, a facility or office fee — even if there is no cost for you for the screening test itself.

And if the screening results in diagnostic services — for example, the doctor finds polyps during a routine colonoscopy — you may be charged for their removal and biopsy.

To tap into these preventive services without paying anything out of pocket, you likely need to use an in-network health provider. Be sure to read the details of your own insurance policy to determine how to identify in-network providers in your area.

Preventive screenings the ACA covers may change over time, but they now include the following:

  • Blood pressure, for every adult

  • Cholesterol, for older adults or people at higher risk

  • Colorectal cancer, for people over age 50

  • Depression, for every adult

  • Diabetes Type 2, for any adult with high blood pressure

  • HIV, for anyone aged 15 to 65 (and at other ages for people who have evidence of increased risk)

For women, additional preventive screenings are covered, including the following:

  • Anemia, gestational diabetes, Rh incompatibility, and hepatitis B, for women who are pregnant

  • Cervical cancer, for women who are sexually active

  • Mammography, for every woman over age 40

  • Osteoporosis, for women over age 60 who are at risk

Other screenings are available to women at risk for sexually transmitted diseases; counseling is offered to women with a higher risk of developing breast cancer; and some forms of contraception, including education and counseling, are offered to all women who could become pregnant. Verify what is covered by your plan and any associated costs.

In addition, the ACA covers screening and counseling for men and women who use alcohol or tobacco products, diet counseling for adults who are at higher risk for developing chronic illness, and obesity screening and counseling for all adults.

Many immunization vaccines are also available with no costs to you. The ACA covers vaccines for flu; measles, mumps, and rubella; hepatitis A and B; pneumonia; and more.

The ACA requires your insurer to give you a Summary of Benefits and Coverage (SBC) — a document that spells out your benefits and coverage in language that’s easy to understand. If you’re shopping for coverage and want to know what a certain plan covers, or if you already have insurance and want to know which preventive services you can expect, check the SBC.