FAIR Health Consumer Access

Prevention and Wellness Care for the New Year

With a new year ahead, now is a good time to think about prevention and wellness. Under the Affordable Care Act (ACA), most private healthcare plans and all Health Insurance Marketplace plans must provide many preventive and wellness services for free, without a copay or coinsurance. If you’re healthy, preventive and wellness services can help you to stay healthy. Do you have some habits that may harm your health, like smoking or a poor diet? Wellness services can help you to get on a healthier track. Screening tests can catch illnesses early on, when they may be easier to treat.

Prevention
Prevention includes services, such as vaccinations and screenings, that can keep you from getting some diseases. Your healthcare provider may recommend that you or a member of your family get certain vaccinations, based on age and other factors. For example, it is recommended that most people get a flu vaccine by the end of October each year. It also is recommended that people stay up to date with COVID-19 vaccines for their age group.

Preventive services also include screening tests. These are tests that are done to see if you have a disease before you have any symptoms. Screening tests can catch illnesses early on, when they’re easier to treat and before they’ve caused a lot of damage.

Whether you should have a certain screening test depends on your risk factors. For instance, being over age 50 is a risk factor for colorectal cancer, because that cancer usually happens in older people.

Screening tests can be done for other types of cancer as well. They can also be done for high blood pressure, diabetes, high cholesterol and more.

Wellness
Wellness services are mostly focused on lifestyle. They can help you to reduce the things that increase your chances of becoming ill—your risk factors. Reducing your risk factors may allow you to avoid getting some diseases. For instance, being overweight or obese puts you at risk for getting type 2 diabetes or arthritis. A weight management specialist can help you to find an exercise program and a weight-loss diet you can stick with.

Types of Services That Are Covered
Under the ACA, three types of preventive and wellness services must be covered by most insurance plans.

• For adults: Covered services depend in part on your age and risk factors. Vaccinations and screening for depression, colorectal cancer, type 2 diabetes and other diseases are covered. Help to quit smoking is also covered.
• For women: Services are covered for women who are pregnant (like breastfeeding support) or wish to avoid pregnancy (like contraception, with some exceptions). Other services include annual well-woman visits and breast cancer screening.
• For children: Standard vaccinations are covered. Screening tests for vision and behavioral problems are covered throughout childhood. Alcohol and drug use screening is covered for adolescents.

You can find out what preventive and wellness services are best for you or your family by talking to your healthcare provider. Also, you can use the MyHealthfinder Tool for recommendations by age and gender. Talk to your insurance provider to make sure the services you’re thinking of are covered by your plan. If you have a Marketplace plan, check out the information on the HealthCare.gov page on preventive services.

Keep in Mind
Here are some things to keep in mind when you’re thinking about getting preventive or wellness services:

• Make sure the provider you use for preventive or wellness services is in your plan’s network.
• If other services have to be done during or after a screening test, they might not be free. For instance, if you have a colonoscopy (a screening test for colorectal cancer), you might have to pay for the anesthesia. Also, sometimes a problem is found and treated during the screening. For example, during a colonoscopy, tissue that looks like it could be cancer might be found and removed. In that case, you could have to pay coinsurance and other out-of-pocket costs.
• Some older insurance plans are not covered by these rules. These are plans that were formed before the ACA was signed and haven’t changed their coverage since. There aren’t very many plans like this still around, but check and make sure yours isn’t one.
• Not every kind of preventive or wellness service is covered. For instance, plans don’t have to cover yearly physical exams for free. Many plans do, though. If you think it would be a good idea to have one, talk to your healthcare provider and find out how much you’d have to pay.
• Some health insurance plans cover more than is called for in the ACA. Check with your insurance provider to see what is covered.
• Your employer may offer employee wellness programs, such as exercise programs or stress management counseling. There may be rewards for taking part in them, like a reduction in your health insurance cost. Ask your employer if any programs like this are offered at your workplace.