Which Preventive Services and Immunizations Are Covered for Children Under ACA?

Now that you have health insurance, you may be wondering what’s covered and what’s not for your dependent child(ren).

By law (namely, the Affordable Care Act — ACA), certain preventive services for children through age 18 must be covered at 100%.  This means no copayment, no coinsurance charge, and regardless of whether or not you have met your annual deductible.

Your child must receive these services from an in-network provider for your plan to cover 100% of the charge.

Preventive Services for Children

Here is a list of the preventive services that must be covered for children ages 18 and under:

TYPE OF SERVICE	DETAILS
Alcohol and Drug Use Assessment	For adolescents ages 11-18.
Autism Screening	At ages 18 months and 24 months
Behavioral Assessments	At ages 0-11 months, 1-4 years, 5-10 years, 11-14 years, 15-17 years
Blood Pressure Screening	For children at recommended ages: 0-11 months, 1-4 years, 5-10 years, 11-14 years, 15-17 years
Congenital Hypothyroidism Screening	Once at birth
Cervical Dysplasia Screening	For sexually active females
Depression Screening	For adolescents
Developmental Screening	For children under age 3; continued monitoring throughout childhood
Dyslipidemia Screening	For children at higher risk for lipid disorders at ages 1-4 years, 5-10 years, 11-14 years, 15-17 years
Fluoride Supplements	For children without fluoride in their water source
Gonorrhea Preventive Medication	For all newborns, once at birth
Hearing Screening	For all newborns
Height, Weight, Body Mass Index	For children at ages 0-11 months, 1-4 years, 5-10 years, 11-14 years, 15-17 years
Hematocrit or Hemoglobin Screening	For children
HIV Screening	For adolescents at higher risk
Immunizations	As recommended (see below)
Iron Supplements	For children ages 6-12 months at risk for iron deficiency (anemia)
Lead Screening	For children at risk of exposure
Medical History	For all children throughout development
Obesity Screening and Counseling	For all children
Oral Health Risk Assessment	For young children at ages 0-11 months, 1-4 years, 5-10 years
Phenylketonuria (PKU) Screening	For newborns
Sexually Transmitted Infection (STI) Prevention Counseling and Screening	For adolescents at higher risk
Tuberculosis (TB) Testing	For all children at higher risk
Vision Screening	For all children

Note: Some grandfathered plans are not required to cover all services.

Immunizations for Children

Here are the covered immunizations for children up to age 18.  These are covered at 100%, with no copayment, no coinsurance charge, and regardless of whether or not you have met your deductible.  The immunization must be given by an in-network provider to be covered at 100%

IMMUNIZATIONS – VACCINES FOR CHILDREN AT RECOMMENDED AGES
Diphtheria, Tetanus, Pertussis/Whooping Cough (DTP)
Haemophilus Influenza Type B
Hepatitis A
Hepatitis B
Human Papillomavirus (HPV)
Influenza (Flu Shot)
Measles, Mumps, Rubella (MMR)
Meningococcal (Meningitis)
Pneumococcal
Polio (Inactivated Poliovirus)
Rotavirus
Varicella (Chicken Pox)

Note: Some grandfathered plans are not required to cover all services.

Check Your Policy Information

For more detailed information, check the documentation you received with your policy.  Be sure you understand what your plan covers before you seek medical treatment, so there are no surprises later!

Give our office a call or send us an email if we can answer any questions for you.

Click here for a list of preventive services and immunizations covered for adults.

Click here for a list of preventive services covered for women.

Which Preventive Services and Immunizations are Covered for Adults Under ACA?

Now that you have health insurance, you may be wondering what’s covered and what’s not.

By law (namely, the Affordable Care Act — ACA), certain preventive services must be covered at 100%.  This means no copayment, no coinsurance charge, and regardless of whether or not you have met your annual deductible.

You must receive these services from an in-network provider for your plan to cover 100% of the charge.

Preventive Services for Adults

Here is a list of the covered preventive services for adults:

TYPE OF SERVICE	DETAILS
Abdominal Aortic Aneurysm Screening	One-time for men of specified ages who have ever smoked
Alcohol Misuse	Screening and counseling at physical exam
Aspirin Use	To prevent cardiovascular disease, for men and women of certain ages
Blood Pressure Screening	For all adults
Cholesterol Screening	For adults of certain ages or at higher risk
Colorectal Cancer Screening	For adults over 50
Depression Screening	For all adults at physical exam
Type 2 Diabetes Screening	For adults with high blood pressure
Diet Counseling	For adults at higher risk for chronic disease
HIV Screening	For all adults at higher risk
Immunizations	As recommended (see below)
Obesity Screening and Counseling	For all adults during physical exam
Sexually Transmitted Infection (STI) prevention	For adults at higher risk
Tobacco Use	Cessation counseling and intervention for all adults
Syphilis	Screening for all adults at higher risk

Note: Some grandfathered plans are not required to cover all services.

Immunizations for Adults

Here are the covered immunizations for adults.  These are covered at 100%, with no copayment, no coinsurance charge, and regardless of whether or not you have met your deductible.  The immunization must be given by an in-network provider to be covered at 100%

IMMUNIZATIONS – VACCINES FOR ADULTS AT RECOMMENDED AGES
Diphtheria, Tetanus, Pertussis/Whooping Cough (DTP)
Hepatitis A
Hepatitis B
Herpes Zoster (Shingles)
Human Papillomavirus (HPV)
Influenza (Flu Shot)
Measles, Mumps, Rubella (MMR)
Meningococcal (Meningitis)
Pneumococcal
Varicella (Chicken Pox)

Note: Some grandfathered plans are not required to cover all services.

Check Your Policy Information

For more detailed information, check the documentation you received with your policy.  Be sure you understand what your plan covers before you seek medical treatment, so there are no surprises later!

Give our office a call or send us an email if we can answer any questions for you.

Click here for a list of preventive services and immunizations covered for children.

Click here for a list of preventive services covered for women.

Preventive vs. Diagnostic Medical Services Under the Affordable Care Act

The Affordable Care Act (ACA) mandates that all qualified health insurance plans (except grandfathered plans purchased prior to March 23, 2010 and still in place) include coverage for ten essential health benefits.  That does not mean these medical services are necessarily free, merely that your health insurance will cover some or all of the cost.

But certain preventive services are free.  This means your health insurance must cover 100% of the service without charging you a co-payment or co-insurance, even if you have not yet met your deductible.

NOTE: you must use an in-network provider to receive free preventive care.

Preventive Services vs. Diagnostic Services

Many people are surprised to learn a service they believed to be preventive — and therefore free — was not considered preventive by the insurance company — and therefore resulted in a medical claim.

It is important to understand the difference between a preventive service and a diagnostic service.

Preventive services are things that prevent health problems.  Preventive care happens before you feel sick.  Examples are immunizations, lab tests, physical exams, certain medications.

Diagnostic services are things that help your doctor understand the symptoms you’re having and diagnose an illness. Diagnostic care happens when you feel sick or have a known health issue.

The tricky part is sometimes the same service may be preventive — and free — under certain circumstances, yet diagnostic — and not free — under others.

How Do I Know if the Care I Receive is Preventive or Diagnostic?

Whether a service is preventive or diagnostic depends on the reason for having it.

In general, a medical service is considered diagnostic if it is done for the purpose of monitoring, diagnosing, or treating a known health issue or symptom.  For example:

If you have a known, already-diagnosed chronic disease like diabetes, and your doctor monitors your condition with certain tests, these tests are considered diagnostic.

If a preventive screening test reveals a health problem and then your doctor orders more tests to further diagnose the exact issue, these tests are considered diagnostic.

If you are having symptoms, like abdominal pain, and your doctor orders tests to figure out the cause, these tests are diagnostic.

A service is considered preventive if it is done for screening purposes, and not based on any symptoms.  Certain preventive services, when done on a recommended schedule (e.g., at a certain age or frequency), are covered at 100%.

The Same Service can be Preventive or Diagnostic, Depending on the Reason

Here are a few examples of services that can be either preventive or diagnostic, depending on the reason for the service:

• Mammogram – preventive if done as a screening based on your age or family history; diagnostic if you have symptoms like pain or have detected a lump.
• Cholesterol testing – preventive if done as a screening based on your age or family history; diagnostic if you were already diagnosed with high cholesterol and your doctor is monitoring your numbers.
• Colonoscopy – preventive if done as a screening based on your age or family history; diagnostic if you have symptoms like bleeding or irregularity.
• Colon Polyp Removal – the removal itself is preventive if done as part of a screening colonoscopy; if sent to the lab for testing, this is diagnostic.

Understand Your Policy

It is best to fully understand the provisions of your health insurance policy when seeking medical care.  You can consult your plan’s documentation for specifics on your coverage.  If we helped you enroll in coverage, you can also give us a call and we’ll be glad to help!