Preventive care can help you stay healthier, reduce your risk of unexpected health challenges and lower your health care costs over time. But there are a lot of questions around what preventive care is and why it’s important to schedule your appointment.

We’ll explain which services are covered under HealthPartners insurance preventive benefits, and the difference between a preventive visit and an office visit. We’ll also answer common questions about preventive services.

What are preventive services?

Preventive services are a range of services like checkups, screenings and immunizations that are designed to prevent illnesses and help keep you healthy. They’re usually provided by a primary care clinician. For something to qualify as a preventive service, the service must take place before a problem is identified. Examples of preventive care services include:

• Certain physical exams
• Immunizations
• Contraceptive counseling
• Men’s health screenings
• Some cancer screenings
• Women’s health screenings
• And more

Preventive care services are included in what you already pay for your health insurance. This means there are no out-of-pocket costs for most members as long as they get the preventive care services their plan covers from a doctor or clinic in your network.

How preventive services are determined and billed

Health plans, including those from HealthPartners, don’t determine which services are considered preventive. Instead, health plans follow the Affordable Care Act (ACA) preventive care rules. These rules ensure that all health insurance companies provide coverage the same way.

When HealthPartners gets a claim from your doctor, we check how the provided service is coded. Your doctor may recommend other care to prevent or screen for conditions based on your specific family or health history. However, the care may not be covered by your preventive care benefit. Care that doesn’t align with preventive care guidelines from the government is covered differently by other parts of your health plan benefits, such as outpatient office visit or lab benefits.

Is preventive care 100% covered?

In most cases, yes. ACA-compliant health plans like HealthPartners must cover 10 essential health benefits, including preventive care services. As long as you get care in your plan’s network, these plans provide preventive care services without charging deductibles, copayments or coinsurance.

What does a preventive visit cover?

At these visits, you’ll have a conversation with your clinician and get screenings, immunizations and other services based on your age and gender, to identify health concerns and help you stay healthy.

Your visit might also include care or treatment beyond preventive services. Other types of care would be covered differently by your plan.

Is a physical considered preventive care?

Yes. A physical is considered preventive care, but only when the services provided are focused on prevention and early detection of disease and symptoms that can lead to more serious health conditions later. If your conversations during a physical lead to diagnosing or treating an existing injury or illness, the visit does not fall under preventive care and could be subject to an out-of-pocket cost.

Preventive visit vs. office visit: What’s the difference?

Preventive visits usually happen while you’re feeling healthy, while office visits are scheduled when you need help diagnosing symptoms or to treat a specific medical condition. Both may include services like exams, immunizations and health screenings, but they are covered differently by your health insurance.

Let’s walk through an example

Bob schedules a preventive visit at his local HealthPartners clinic. During that visit, he chats with his doctor about how he’s been feeling and gets his annual physical exam.

Bob’s blood pressure has been trending a little high the past few visits, so his doctor recommends that they run a few blood tests to see what’s going on. He also has a history of gout, so his doctor checks on this and refills a prescription that helps prevent gout flare ups. After wrapping up with his doctor, Bob stops at the lab to have blood drawn and leaves feeling like he’s got what he needs to stay healthy.

A few weeks later, Bob gets an Explanation of Benefits from HealthPartners that shows how the visit was covered by his insurance and what (if anything) he needs to pay out of pocket.

1. Bob’s physical and general health screenings (like checking his blood pressure) are preventive services that fall under preventive care guidelines, so they were covered 100% by his plan’s preventive care benefit.
2. Bob’s lab work is not considered a preventive service since his doctor recommended the blood test based on a potential diagnosis. The lab work cost was covered by his plan’s non-preventive lab benefit.
3. Since Bob had a previous diagnosis of gout, that part of the visit is also not considered a preventive service because it addresses an ongoing condition. It was covered by his plan’s outpatient office visit benefit.
4. As a result, Bob has some out-of-pocket expenses for the lab and office visit portions of his appointment.

Common questions about preventive care, coverage and billing

There can be a lot of confusion about what services are considered preventive care. We’ll walk you through some of the most common questions we see to help you better understand HealthPartners preventive care benefits.

Are annual health screenings always considered preventive services?

It depends. Remember, for something to qualify as a preventive service, it must take place before a problem is identified. So services like colonoscopies or mammograms may or may not be considered a preventive service, depending on your health situation.

For example, if a person gets a mammogram during an annual breast cancer screening, that’s preventive. But if something irregular is detected and further scans or additional follow-up care is needed, those services are no longer considered preventive, and you may have some out-of-pocket costs.

Are both 2D and 3D mammograms covered as preventive services?

Most HealthPartners plans cover both 2D and 3D mammograms as a preventive service.

Is all blood work considered preventive care?

It depends. Routine blood work for existing conditions like hypertension, high cholesterol and diabetes is not considered a preventive service. This goes back to the idea that in order for something to be preventive, it has to be previously unknown. Like we saw with Bob’s example, once a condition has been diagnosed, members will need to tap into other areas of their coverage, which may have some out-of-pocket costs.

Do I have to wait 365 days between preventive visits?

To be covered as preventive services, most HealthPartners plans don’t require annual checkups or well child exams to be at least 365 days apart.