Over the past few months IBX has been hitting the road to help consumers understand the important changes included in the Affordable Care Act. We have been meeting people at health clinics, community fairs, seminars, festivals, YMCAs, and many more places throughout the region.
One question that comes up most often is, “What is preventive care?”
Consumers have heard that the health care law requires health insurance plans to cover 100 percent of the costs for preventive care. However, a question we often hear is, “How do I know what is considered preventive care?”
Preventive care is the care you receive to prevent illnesses or diseases. It also includes counseling to prevent health problems. Providing these services at no cost is based on the idea that getting preventive care, such as screenings and immunizations, can help you and your family stay healthy. Preventive care may also help reduce your health care costs down the road if you catch a problem early, or if an immunization keeps you from getting a serious illness.
Here are a few pointers about what’s covered, plus tips to help you know what to expect.*
A few examples of preventive care services:
- Wellness visits and standard immunizations
- Screenings for blood pressure, cancer, cholesterol, depression, obesity, and Type 2 diabetes
- Pediatric screenings for hearing, vision, autism and developmental disorders, depression, and obesity
See the full list of preventive care services.
Is there ever a chance you might have to pay?
Many preventive services are 100 percent covered by insurance. For example, if you have an IBX plan, you won’t have to pay anything for these services if you see a doctor or health care professional within our network.
But there’s a chance that you may still be asked to pay after a visit for additional services.
It’s important to make sure that you and your doctor are on the same page. Always ask what services your doctor is providing. What you pay will also depend on how he or she bills your health insurer.
- If a preventive screening uncovers something that could be serious, your doctor may order additional tests, schedule a follow up visit, or refer you to a specialist. The additional tests and follow-up may not be 100 percent covered.
- If a preventive screening uncovers something that your doctor says needs to be addressed right away, then that visit may switch from being prevention to treatment. Also, if you see a doctor to diagnose, monitor, or treat an illness or injury, the visit is not considered preventive care. In these cases, your normal cost-sharing would apply (copayments, coinsurance, or deductible).
- There may be limits on the number of preventive services you can receive with no out-of-pocket cost. For example, in some plans, a wellness exam may be 100 percent covered once every other year. However, if you get a checkup more often, your normal member cost-sharing fees may apply.
In any case, it’s always a good idea to check with your insurance company ahead of time on the services that will be covered.
What if you are charged for a preventive care service?
The Affordable Care Act made a lot of changes and many people are still getting used to the new rules. If you’re charged for a service you believe should have been 100 percent covered, here’s what you should do.
- Keep your paperwork. You can save a lot of time later if you keep your paperwork and bills handy.
- Check with your doctor’s office. Ask what services were billed to the insurance company. Does it match what you remember from your visit? If it turns out there was a mistake, the doctor’s office can send a corrected claim to the health insurance provider.
- Check with your health insurer. Ask what services the doctor’s office billed. Does it match what you remember from your visit?
- Ask your doctor for a reimbursement. If your doctor agrees that a mistake was made with your bill, ask your doctor to reimburse you the appropriate out-of-pocket expense.
*The Affordable Care Act allows certain health insurance plans that went into effect before March 2010 to be considered “grandfathered,” meaning they are not required to cover 100 percent of preventive care services.