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What’s Considered ‘Preventive’? How to Know

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By Lisa ZamoskyOctober 22, 2015
From the WebMD Archives

Most insurers are now required to cover the full cost of preventive care, such as wellness check-ups, vaccinations, and screenings. But, as you may know, it can sometimes be difficult to determine which medical services and tests are truly considered preventive.

How can you determine if your visit is considered preventive and likely free? Here are 6 things to consider.

1. Know the law. Under The Affordable Care Act, vaccinations, cancer and other health screenings, wellness exams, and FDA-approved contraceptives are free in most cases. Health plans were already in place when the law took effect March 23, 2010 – called “grandfathered” plans – don’t have to comply with this part of the law.

2. Pay attention to details. There are guidelines set by medical and scientific authorities that determine whether or not medical services are considered preventive. The specific recommendations will decide if your visit is covered in full by your insurer.

For example, colonoscopies are covered in full for people over the age of 50. If you’re 35 and go for a screening, you’ll likely be on the hook for some portion of the cost.

For a complete list of preventive health services available cost-free, see the Kaiser Family Foundation’s Prevention Services Tracker.

3. Know your insurer’s rules. Your insurer has some wiggle room when it comes to interpreting the medical guidelines. For example, insurers must cover all forms of FDA-approved birth control pills, but that doesn’t mean your particular brand is on the list of those your particular plan covers. Instead, your insurer may pay only for the generic form.

4. Stay in network. If you want cost-free preventive care, you must stay in your health plan’s network. Care provided by doctors outside your plan’s network will cost you.

5. Be clear about the purpose of your visit. When you call to make your appointment, be sure to tell the person you speak with that you’re coming in for a preventive visit, such as a woman’s wellness exam.

Keep in mind that if you discuss an existing health issue during the same visit, you may get a separate bill for that even though the preventive service must be without cost.

6. Question unexpected bills. Always question any charges you don’t understand or think should be free. Often the mistake is a simple billing error that can be easily cleared up by calling your doctor’s office to explain it was a preventive visit.

Still hitting a roadblock at the medical billing office? Contact your insurer. Your health plan may also be able to step in on your behalf to get a payment issue resolved. If coverage is denied, you can also file an appeal with your health plan.

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