Preventive care can help you stay healthier and, as a result, lower your health care costs. But there’s a lot of confusion around what preventive care is and why it’s important.
We’ll explain which services are covered under HealthPartners preventive benefits and the difference between a preventive visit and an office visit. We’ll also clear up common misconceptions about preventive services.
What are preventive services?
Preventive care services are rolled into what you already pay for your health insurance. This means no out-of-pocket costs for most people as long as you get preventive care services your plan covers from a doctor or clinic in your network.
How does HealthPartners determine what’s a preventive service?
Health plans, including those from HealthPartners, do not determine which services are considered preventive and instead must follow the Affordable Care Act (ACA) preventive care rules. This ensures health insurance companies provide coverage the same way.
The ACA primarily defines preventive services as those with an A or B rating under the United States Preventive Services Task Force (USPSTF) guidelines. These include things like:
- Some physical exams
- Contraceptive counseling
- Some cancer screenings
- Women’s health screenings
- And more
When HealthPartners gets a claim from your doctor, we check checks how the provided service is coded under the USPSTF. Codes that align with an A or B rating are covered by your preventive care benefit. Codes that don’t align are covered by other parts of your health plan benefits, such as outpatient office visit benefits or laboratory benefits.
A preventive visit usually is an appointment with a primary care clinician to evaluate your health, even though you’re feeling healthy. At these visits, you’ll get a physical and any screenings that are recommended based on your age and gender. Preventive visits help identify health concerns before they become a long-term condition and help ensure you’re doing what you need to do to stay healthy.
Preventive services often happen at preventive visits. But preventive visits might also include care beyond preventive services when it’s related to keeping you healthy. In other words, one visit to the doctor could result in two or more types of care that are covered differently by your plan.
What’s the difference between a preventive visit and an office visit?
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.
- Bob’s physical and general health screenings (like checking his blood pressure) are preventive services that fall under USPSTF guidelines, so they were covered 100% by his plan’s preventive care benefit.
- Bob’s lab work is not considered a preventive service since his doctor recommended the blood test based on a potential diagnosis. The cost was covered by his plan’s non-preventive lab benefit.
- 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.
- As a result, Bob has some out-of-pocket expense for the lab and office visit portions.
Common misconceptions about preventive services
There can be a lot of confusion about what services are considered preventive care. We’ll walk you through some of the most common misconceptions we see to help you better understand HealthPartners preventive care benefits.
Misconception 1: Because I scheduled a preventive visit, it will be billed as 100% preventive care
This isn’t always the case. The older you get, the less likely you are to have a visit that is 100% preventive services. As you reach certain stages in life, conversations with your clinician about a pre-existing condition, family health history or current symptoms become more likely and may shift your visits from preventive to regular office visits.
Misconception 2: Annual health screenings are always 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.
Misconception 3: 2D and 3D mammograms are not both preventive services
False. All HealthPartners employer-based, individual and Medicaid & Medicare plans cover both 2D and 3D mammograms as a preventive service.
Misconception 4: All blood work is covered as a preventive service
It depends. Routine blood work for 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.
Misconception 5: You don’t have to wait a full 365 days to get your next annual checkup or well child exam
True. 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.
Not sure if something is considered preventive for you? Contact your insurance company.
If you have HealthPartners insurance, you can: