Since the passage of the Affordable Care Act, most insurers must now provide preventive benefits without any form of cost sharing. And yet, millions of Americans are still missing out on free (and potentially life-saving) preventative health care services, like flu shots and cancer screenings.
If pocketbook concerns are keeping you from taking care of your health, take a second look. You may find that the preventive services you want are covered without cost to you.
Free benefits — Really?
Of course, it’s misleading to call preventive benefits completely free. You pay for them in the cost of your health insurance premiums. But you may as well use these benefits because, after all, you’re already paying for them. Recent studies show that preventive benefits may save 2 million lives and $4 billion dollars annually.
Furthermore, the ACA doesn’t guarantee free preventative treatments for 100% of insured people. Some insurance plans were given a pass on providing preventative services if they were implemented before March 2010. In 2016, 23% of workers who receive benefits through their employer are enrolled in a grandfathered plan and may not receive full free preventive benefits.
There is also the risk that medical providers may bill patients for services that should be free. Those types of errors are caused when medical billing offices unwittingly bundle covered and uncovered services, when your bill contains an error, or when your insurer errantly denies a claim.
Office visits and preventive services are often billed separately. This means you may receive a legitimate bill even when you thought you were going to receive free care. The only way to avoid this conundrum is to ask for costs in advance. You may also be billed if you use an out-of-network provider.
Below, we cover the preventive benefits you can expect to receive for free, and the times that they may lead to unexpected medical bills.
Benefits for adults
Preventive benefits for all adults fall into six categories. Some benefits are limited to at-risk groups or women only. Before you use a preventive benefit, ask your doctor if you qualify for free screenings. If you don’t, you will have to pay a bill.
Some preventive services will be built into an annual physical, but you can request the services as you need them.
Remember, the preventive service is free, but you may need to pay for ongoing treatment if you uncover a health problem.
- Breast cancer screening (mammogram)
- Cervical cancer screening (pap smear)
- HPV screening (pap smear)
- Skin cancer counseling
- Colorectal screenings (fecal occult blood testing, flexible sigmoidoscopy, colonoscopy)
- Lung cancer screening (tomography)
Insurers (except grandfathered insurers) cannot impose an extra charge for polyps removed during a colonoscopy. They also cannot charge for medically necessary anesthesia.
Treatment for Chronic Conditions:
- Screening for the following diseases: abdominal aortic aneurysm, diabetes (blood glucose), hypertension (blood pressure), hepatitis B, hepatitis C, latent TB infection, liquid disorders, osteoporosis
- Depression screening
- Low-dose aspirin (adults with cardiovascular or colorectal disease risk factors)
Except obesity management and prescribed aspirin, you must pay for chronic condition treatments through your insurer. This means treating chronic conditions will include cost sharing.
Many chronic condition tests require a blood or urine sample. If your doctor is worried about your health, they may test for multiple uncovered diseases. In that case, you can expect to pay a fee for lab work.
You may also see a charge if a medical biller uses the wrong medical billing codes. If you end up with an unexpected bill, request an itemized bill and an explanation of benefits. You will see on the bill if any you have fees associated with the covered screening. When you see fees for covered screenings, call your doctor to have them adjust the bill. You can also ask your insurer to adjust the claim for you.
Free Health Promotion Treatment
- Alcohol misuse
- Obesity screening and management
- Diet and activity counseling for cardiovascular disease prevention
- Falls prevention (adults 65+)
- Tobacco cessation
- Well-woman visits
- Intimate partner violence screening and counseling
Initial counseling and tobacco cessation pharmaceuticals are covered at 100%, but your doctor may recommend therapies and counseling not covered by insurance. Be sure to ask if counseling will be billed as a preventive benefit.
All immunizations recommend by the Advisory Committee for Immunization Practices (ACIP) must be covered as preventative benefits. This includes over 20 types of immunizations including the annual flu shot.
If you aren’t sure whether an immunization will be covered by your insurance, ask your doctor before you agree to the immunization.
Sexual Health Treatment
- Screening tests for chlamydia, gonorrhea, syphilis, HIV infection
- STI counseling
- HIV counseling
- Contraceptive services
Insurers must cover the lowest cost version of 18 unique forms of birth control. Treatment for sexually transmitted diseases or infections is not covered as a preventive benefit.
Lab work for sexually transmitted diseases that are not listed will cost extra. Request cost estimates for all tests and screenings even if they are part of your standard wellness visit.
- Anemia, bacteriuria, gestational diabetes, HIV, hepatitis B, syphilis screening
- Depression screening
- Folic acid supplements
- Preeclampsia preventive medicine
- Tobacco cessation behavioral cessation support
- Breastfeeding counseling, supplies, and support
Obstetricians commonly ask for tests outside of those listed above. You should expect to pay lab fees for those tests. Most obstetricians can provide clients with a list of routine pregnancy tests and associated costs. In addition to lab fees, you should expect to pay for ultrasounds, labor and delivery fees, and facility fees during your pregnancy and birth experience.
Benefits for Children
Preventive benefits for children are more robust than preventive services for adults. Nearly all procedures provided during scheduled well-child visits will be covered as preventive services. This includes regular checkups, screenings for childhood diseases and disorders, and immunizations.
If your child provides a blood or urine sample you may want to ask about lab fees, but all other services will be free.
Children at risk and sexually active adolescents can receive all the preventive benefits that adults receive in addition to those specific to children.
Regular well-child visits will make it easy for you and your child to take advantage of any preventive benefits available to you.
Final word: Don’t neglect preventive benefits
Preventive coverage can help you catch and cure otherwise deadly diseases. Curing early-stage diseases often costs less than later-stage treatments, and early treatments may save your life. Recent studies show that preventive benefits may save 2 million lives and $4 billion dollars annually.
These services come with no additional cost sharing to you. Take advantage of preventive coverage; you can’t afford to neglect your health.