Federal health care reform promises to make it easier and more affordable for people to access care. As part of that effort, most health insurance plans now must offer many types of preventive care at no cost to the patient.
But confusion remains about what exactly constitutes the "preventive care" covered by this provision of the Patient Protection and Affordable Care Act.
Altogether, 16 types of preventive services are covered for adults, and 27 for children. For health plans that began after Aug. 1, 2012, an additional eight services are available to women.
You don’t have to pay any deductible, co-pay or co-insurance fees for such services performed by a provider in your health insurance plan's network.
How Obamacare will save you money on preventive care
A list of eligible preventive care services can be found on the U.S. Department of Health and Human Services’ HealthCare.gov website. Many can be grouped into categories, such as:
Well visits and checkups. Things like your annual physical, well-woman visits, and well-baby and well-child visits are covered. Several visits by children over the course of a year typically are covered. But if you are an adult, look closely at your plan details.
“Most plans will limit you to one preventive checkup like this per year,” says Keith Mendonsa, a consumer specialist at eHealthInsurance.com. “If you go in for a second one, it may be applicable to your deductible, or you may have a copayment.”
Immunizations. Adults can receive 10 types of immunization at no cost, while children can access a dozenpreventive vaccines. These include standard immunizations such as measles/mumps/rubella and tetanus/diphtheria/pertussis, as well as the flu shot.
Screening for major diseases and conditions. This includes testing for diseases such as breast cancer, type 2 diabetes, cervical cancer, colorectal cancer (over age 50), HIV, osteoporosis (over age 60), autism and depression.
Counseling and prevention. No-cost screening is available to test for conditions such as:
• Blood pressure.
• Anemia (pregnant women).
• Hearing (newborns).
• Vision (children).
• Lead exposure (children).
In addition, counseling and screening are available to help with issues such as diet and obesity, tobacco use and alcohol abuse.
Learning about preventive care services
These preventive services commonly are labeled as “free.” But that’s not quite accurate, according to Vicki Veltri, state health care advocate in the Connecticut Office of the Healthcare Advocate.
“Preventive care is provided without cost-sharing – it’s not technically ‘free,’ since the insurer must still pay the provider for the service,” she says.
Despite this no-cost coverage, many people remain unaware of the new benefit, says Amy Bach, executive director of United Policyholders, a nonprofit group that provides insurance information to consumers.
“There is confusion on all sides,” she says.
However, Veltri thinks growing numbers of people are aware of the changes. She hears anecdotal evidence that people are seeing physicians more often, and notes that many doctors are placing notices in their offices informing patients about the no-cost services.
“I think this is one of the most successfully promoted provisions of the Affordable Care Act,” she says.
While no-cost coverage sounds great, beware of potential and unexpected financial landmines along the way. For starters, not all preventive care is free.
“There are definitely services that some people would view as preventative that are not included,” Bach says, listing examples such as orthotics, acupuncture, and nutritional counseling for people who are not obese.
Also, health insurance plans in place before March 23, 2010 – when health care reform became law – don’t have to comply with the new rules. However, that problem isn’t as big as it might seem, Veltri says.
“Those plans are certainly allowed to provide preventive services without cost-sharing, and many do,” she says.
You also may owe fees if you do not see a physician who is “in network” for your health plan, or you have an HMO plan and fail to get a referral to a specialist through your primary care physician.
"Straying outside of your insurer's network of providers can result in higher or unexpected charges," Mendonsa says.
The nature of your visit to the doctor adds another wrinkle to the no-cost equation. You may visit your doctor for both preventive services (such as an immunization) and treatments (such as for an ongoing heart condition) at the same time. In this case, the preventive service may not be eligible for no cost-sharing.
“Whether cost-sharing applies depends on what the primary purpose of the visit was,” Veltri says.
Finally, testing during a preventive exam that goes beyond general recommendations might not be covered at no cost to you.
“If a provider orders a test that goes beyond the screening recommendations, (the patient) may face a cost in the form of cost-sharing for a lab test or imaging test,” Veltri says.
Still confused? Mendonsa suggests getting a copy of your health insurance plan’s “summary of benefits and coverage” from your insurance company or employer.
This document provides a basic summary of what costs to expect for a variety of health insurance services, including preventive care and lab fees. The health care reform law mandated creation of this document.