Under the Affordable Care Act, or ACA for short, preventive screenings should be covered without copays or deductibles for those with health insurance. This is true whether that be a small-group plan, a Marketplace plan, or a Medicare Advantage plan. But as many enrollees use their health coverage, they are discovering what should happen in theory doesn’t always happen in practice. Here are some reasons you might get charged for a preventive service—and what you can do about it.
Don’t skip your preventive services
Before we start, let’s make it clear that we are not advocating for you to skip your preventive check-ups! Data shows time and time again that early detection leads to better outcomes: Fewer treatments, fewer costs, fewer complications, and fewer invasive treatments. Preventive care saves lives, full stop.
However, the data also says a small number of Americans actually complete every preventive screening. And despite record high numbers of individuals with health coverage this year, the number of adults over 35 who get all recommended preventive health services is at an all-time low. The more rural the area, and the more socioeconomic inequality that area has, the lower the number gets.
What’s worse, approximately one in three people with employer coverage may have an undetected chronic condition.
Know what services are covered
The best offense is a good defense, so know what services should have no cost sharing. There are preventative health benefits that must be covered by your health insurance without any cost sharing by way of copays or coinsurance. This must be true even if you have not met your deductible. All states must comply with this list, but each state can add more if they see fit.
Some states might add dental care as an essential health benefit in the next few years. States can add this starting in 2027.
Healthcare.gov lists these preventative health benefits on their website for Marketplace plans:
| Abdominal aortic aneurysm |
Depression |
Hepatitis C |
Obesity screening |
| Alcohol misuse |
Type 2 diabetes |
HIV screening |
STI prevention & Syphilis screening |
| Blood pressure |
Diet counseling |
PrEP medication |
Statin prevention |
| Cholesterol |
Fall prevention |
Immunizations |
Tobacco use screening |
| Colorectal cancer |
Hepatitis B |
Lung cancer |
Tuberculosis screening |
The list for Medicare is a lot more expansive, so memorizing the whole thing might not be an easy feat. Most of the time, the items listed above are good to go. We suggest using your “Welcome to Medicare” or yearly wellness check included with original Medicare to see what ails you, then taking it from there. Or, if you have a Medicare Advantage plan, check your summary of benefits.
Same goes for your employer group plan: unless grandfathered otherwise, your plan should cover the aforementioned health benefits. Use your carrier’s app or check your summary of benefits for more details.
But what if I get a bill?
Unfortunately, enrollees sometimes get bills anyway. One study found one in four individuals got a bill for a service that should have no cost-sharing. On top of that, 40% of people delayed or avoided preventive care because they were worried about being one of those one in four. The best way to tackle this is to know the game, and know how to play.
Know your networks
The first pointer is the easiest to follow. Make sure you stay in your plan's network. This is the caveat to the zero cost sharing preventive services offer. The plan can charge you for part or all of the cost if you’re out of network.
If you are a Medicare beneficiary, ensure your provider accepts assignment. This guarantees they won’t tack on any additional charges beyond what Medicare pays, regardless of what the appointment is for. You, of course, have to pay that extra. Just ask when you schedule your appointment.
It boils down to billing
How your provider bills might explain some of the costs. For example, any tools, surgical trays, or equipment might be itemized separately from the preventive service, resulting in a bill.
If this happens, call your carrier and dispute the bill. Plans do not generally intend for this to occur. The provider might not understand the billing process—or worse, knows exactly what they’re doing and is hoping you don’t notice.
If a practice is owned by a private equity firm, which is particularly prevalent in specialty care providers like gastroenterology, this situation is more frequent. Do your homework and read reviews.
The funds are in the follow ups
Remember, only the preventive service itself is covered. If any follow ups occur to discuss the results or treat what is discovered, that is fair game for bills. If additional tests are necessary, those can be billed to you too.
Visit your PCP
PCPs are your first line of defense in saving money across the healthcare board. They can perform some preventive care, look at your family history to see where you should focus your energy, and hopefully reduce your long term costs. Get with them first before trekking out to a specialist.
Overall
We’ll say it again: do not skip out on preventive care! It can save you money, and save your life. Just make sure you are armed and ready with ways to navigate the world of preventive care before you venture out there. If you get a bill, look it over, don’t just blindly pay it. And if you are still worried about paying for those additional tests or treatments after the preventive care, give us a call. We can help you find a plan that fits your unique needs.
Action Benefits : Mar 18, 2024 3:00:23 PM
Action Benefits