When preparing for a preventive care visit it is important that you understand what is typically covered and not covered at 100% under the Affordable Care Act.

 

These tests are often fully covered when ordered as part of a preventive care visit and when no symptoms or underlying conditions are present:

• Cholesterol screening

• Blood pressure screening

• Diabetes (Type 2) screening

• HIV screening, STI screening, hepatitis B and C screening

• Pap smears and HPV testing

• Colorectal cancer screening (screening colonoscopy)

• Mammograms

• Immunizations (flu shots, Tdap, etc.)

 

These tests may be ordered at the same visit, but unless there’s a medical indication or diagnosis, they won’t be covered as preventive and could result in out-of-pocket costs.

• Comprehensive metabolic panels (CMPs) – measures kidney and liver function

• CBC panel – measures red and white blood cells

• Iron studies

• Vitamin D level

• B12 levels

• Thyroid function tests

• Urinalysis

• Electrolyte panels

 

What can you do to avoid surprise charges?

• Ask your provider what tests they plan to order and whether they fall under ACA-mandated preventive services.

• Request only covered preventive tests be performed unless necessary

• Contact Regional Care to confirm if a specific test is preventive or diagnostic according to your plan

• Don't be afraid to ask questions about costs. Do I really need this test? What are the risks? What if I don't do anything? About how much will it cost?

• It’s important to remember that the ACA is subject to change.

 

During a preventive care visit, if you discuss or receive care for issues that aren’t covered as preventative care under the ACA, you could be billed for the visit. Example:

Mary scheduled an annual physical exam with her primary care doctor. She’s been experiencing joint pain over the past few months and planned to wait to discuss this with her doctor during the visit. During her appointment, Mary mentions her joint pain. After the examination, the doctor prescribes Mary a prescription, orders a CT scan, and refers Mary to a specialist. A month later Mary is surprised to receive a bill in the mail from her primary care doctor for the knee examination. She was seeing her doctor for her annual exam, so shouldn’t this be covered under the ACA? Unfortunately for Mary, the answer is no. Mary’s primary care doctor performed a joint examination, sent in a prescription, and diagnosed the pain with an actual diagnosis code in the providers’ computer system. Mary was billed for the time spent discussing and treating her knee pain, which is outside of what the ACA specifies as part of an annual physical exam.

 

Visit www.healthcare.gov/coverage/preventive-care-benefits for a description of preventive care services under the Affordable Care Act.

​

Click here to download this information as a PDF