Both the Affordable Care Act (ACA)—commonly called “Obamacare”—and Medicare make a big deal about preventive services that are covered without requiring beneficiaries or policyholders to pay a deductible, use coinsurance or make a co-payment. Depending on your age, such services as a regular preventive mammogram or a routine colonoscopy (for adults over age 50) require no additional out-of-pocket cost to you even if you haven’t met your annual deductible. You are also entitled to an annual wellness visit with your doctor to review your current health status and lay out a plan to improve it (if necessary).
Sounds great, doesn’t it? And it is. But like most things involving health insurance coverage, there are a lot of strings attached. For many people, what they thought was a free service ends up costing them a good deal of money. How to know when a preventive or wellness service is really free—or not…
• Know the terminology. A friend of mine complained that he was billed by his doctor for an annual physical when his insurance policy stated he was entitled to a free annual wellness visit. He assumed that an annual physical is a wellness visit—a logical assumption to make. But under both Medicare and the ACA, they are not the same. A similar situation applies to certain mammograms, colonoscopies and other screening tests. These are free only for preventive screening (that is, when you have no symptoms). If a test is ordered because of a symptom or because the doctor suspects something may be amiss, it is not free—and you can be charged. To add to the confusion, even if you were symptom free, if something is discovered from the test, you still might be charged!
• Know what’s covered. It’s important that you check out what preventive and wellness services you are entitled to under your health plan. If you are on Medicare, I recommend checking the list of covered services on the Medicare.gov website (put “Your Medical Coverage” into the search box). You also can call 800-MEDICARE to ask about covered services and terms of coverage. If you are insured on a plan governed by the ACA, go to HHS.gov and search for “preventive care.” You also should contact the insurance company that issues your policy to find out the full terms. And if you are covered through your employer, confirm what the free preventive services are directly with the insurer.
• Watch what you say. As noted above, an annual physical is not the same as a wellness visit. In fact, other than taking your blood pressure or reviewing tests that you’ve already had, the purpose of the wellness visit is to discuss what you should be doing to maintain your health. If you even say something like “I’ve had a ringing in my ears lately, can you check it out?” the visit is no longer considered a wellness or preventive visit—it becomes a physical or checkup, for which you will be charged…plus you will also be charged for treating your condition (effectively paying for two visits). So be very clear with your doctor that you are there for a free wellness visit…and that you will make another appointment to discuss a symptom or treatment of a chronic condition.
• Don’t become overwhelmed. As confusing as all this can be, remember that preventive health services really can help you live a longer, more active life. Make sure your doctor knows that you want all the free preventive services you are entitled to and that are appropriate for your age and condition.