Under the Affordable Care Act, most insurers must cover the full cost of preventive care such as checkups, vaccinations, and screenings. But many people end up surprised when the doctor visit they thought was free suddenly comes with a bill. What gives?
Here are five things to think about to avoid surprise costs at your next doctor’s appointment.
1. Know what’s considered preventive: The Affordable Care Act requires most insurers to cover the full cost of many preventive services with no co-payments or other out-of-pocket costs. (If you have a grandfathered health plan, however, this requirement does not apply.)
Preventive services include vaccinations, annual well-visits, colonoscopies, cancer and other health screenings, which in most cases are available free of charge. You can view a full list of preventive services at Healthcare.gov.
2. Pay attention to the details. The guidelines for preventive services are set by the U.S. Preventive Services Task Force, a panel of health care experts. It’s not enough to look for the services the task force recommends; you also need to be mindful of the specific guidelines of each service.
For example, although colonoscopies are a recommended preventive test, the guidelines state that it’s only preventive for people 50 and older when recommended by a physician. If you go for a colonoscopy at 40, the test likely won’t be considered preventive, and you’ll be charged.
3. Know your health plan’s rules. Health plans have some flexibility when it comes to interpreting the guidelines.
For example, mammograms are a preventive exam recommended every 1 or 2 years for women over 40. That means your health plan may pay for the test each year for women over 40, or it may only pay for the test once every 2 years. You need to confirm your plan’s coverage guidelines.
4. Provider networks matter. Even if the nature of your visit is preventive, if you go to a doctor outside of your plan’s network, all bets are off. You can be charged for the visit.
5. Medical complaints aren’t preventive. Even if you’ve gone in for a well visit, once you ask the doctor to examine you for the headaches you’ve been having for the past 6 months or to check on your stomach troubles, the visit is no longer preventive and you’ll be charged.
You can avoid unexpected bills by being clear with your doctor’s office about all the reasons for your visit when you make your appointment.
Have you been surprised by a bill for what you thought were preventive services? Please share your experience in the comments section.