We hear of so much bad news in health care these days: Premiums rising, not enough physicians to go around, health plans covering less and less, etc. Well, the good news from the health reform front is that many plans must now provide a number of preventive care services free of cost. This means that cancer screenings, diet counseling, or your child’s immunizations could all be covered 100%.
There are a number of rules and limitations to watch out for though, so don’t expect a free-for-all next time you’re at the doctor’s office. Here’s a crash course on what’s covered, what’s not, and how to know.
Who does this apply to?
These benefits only apply to people with individual plans or plans sponsored by their employer, which were created after March 23, 2010. When your new policy year begins (usually on January 1st), the benefits become effective. Plans that existed prior to March 23, 2010 are known as grandfathered health plans and unfortunately, they are exempt from some of these new rules. However, you’re not completely out of luck if you think you are in an older plan: If the plan makes significant changes to the policy, which either reduces your benefits or increases your costs, it can lose its grandfathered status.
The best way to find out whether you have these preventive benefits is to check your plan documents (they must disclose whether the plan is grandfathered), or call the provider (or the plan administrator if you have an employer-sponsored plan). If you are connected to a site like Simplee or Cake Health, you can also check your plan coverage there.
If you have Medicare, many preventive services are also free. For a list, visit Medicare.gov.
The list of covered services is pretty long: Several dozen screenings, tests, immunizations, and counseling, including some benefits specific to women and children. Keep in mind that some services are limited to people who are at risk for certain diseases. For example, type II diabetes screenings are only covered for adults with high blood pressure.
For a full list of covered services, visit Healthcare.gov.
Network rules still apply.
If you have an HMO or PPO, don’t try to go to an out-of-network provider. It won’t be covered (or for a PPO, you’ll still have co-insurance). The same rules still apply.
But watch out for add-ons…
Free really does mean free: You won’t have to pay any co-pays, co-insurance or even meet your deductible first. However, the reality is that preventive care services don’t always come as a stand-alone service.
Picture this: You want to get a bone mass screening because you know that women your age are at risk for osteoporosis. Would you make an appointment just for this? Odds are, you would combine it with another appointment. If this is the case, the physician can bill you for an office visit, even though the osteoporosis screening itself will not be charged.
Or, let’s say you get a colorectal cancer screening and the results call for additional testing. Any related follow-up may not be included as a free benefit. That being said, be aware of billing methods and ask about whether any additional tests or checkups are included as part of the original service.