Understanding Preventive Care Coverage

One of the changes to Healthcare over the past year included the coverage of recommended preventive services without charging out of pocket costs through the Affordable Care Act. With this change, many Americans have gone to the doctor for covered screenings including eye chart vision screenings, mammograms, and colonoscopies. However, confusion arises if they receive a bill for these screenings.

It is important as significant changes are made to fully understand what specifically is covered by your health plan. For instance, you may want to be aware of the following regarding Preventive Care Covered Services:

·         Your plan must have adopted this change. Preventive care coverage currently only applies to plans created after 3/23/2010 with plan years beginning after 9/23/2010. If your plan is grandfathere d or does not begin after these dates, this may not apply to you yet. For clarifications of grandfathered v. non-grandfathered plans, check out McGohan Brabender's Health Care Reform Website.

·         Your services must be coded and billed as preventive. Preventive care has restrictions regarding the screenings being preventive. For instance, a colonoscopy coded by the provider as a preventive will be covered. However, a colonoscopy that is coded as diagnostic by the provider (which would happen if the patient were to complain of symptoms requiring the procedure) will only be covered as a normal diagnostic procedure according to your specific benefits plan. It is important to discuss this with your provider before your exam so that you fully understand the procedure they plan to perform.

·         You must go to an in network provider. Carriers are only required to fully cover preventive care services at their in network providers. If you choose to go to a provider that is out of network for your plan, you may be charged a fee.

·         You may be responsible for the cost of the office visit. While your actual preventative care screening may be covered in full, you may still be billed for the office visit.

·         You must be of age for the preventive care. Some preventive care screenings are based on your age. If you are not within the age range to receive the preventive care screening yet, you may be required to pay for the cost of the exam.

For more details regarding preventive care, you can check out the following covered services documents:

Preventive Services covered under the Affordable Care Act


Or check out http://www.healthcare.gov/law/provisions/preventive/index.html