What’s the Deal with Preventive Care Being Covered at 100%?
When you go for a routine preventive visit with your primary care provider, you might be surprised if you're asked to pay at the time of service or receive a bill later. You might think, “I thought preventive care was free?”
First, let’s clear up the misconception that any medical service is truly "free." There’s always a cost involved because your doctor or provider expects to be compensated for the services provided. When we say preventive care is "free," it actually means you don’t have to pay anything out of pocket. However, the cost is covered by your health plan.
In some cases, laws require health plans to cover preventive care 100%.Even if a plan isn’t legally required to do this, it might still cover preventive services completely to encourage members to seek necessary care without financial concerns. This approach helps avoid situations where a patient might delay or skip important tests or procedures due to cost, potentially leading to more serious health issues and higher costs later.
Here’s how it works: While the service itself isn’t free, preventive care visits are typically covered without any cost to you. However, the U.S. healthcare system is complex, and determining what qualifies as preventive care can be tricky.
When scheduling an appointment for preventive care, such as an annual physical, you expect the visit to be fully covered. But if you discuss a chronic condition, like high blood pressure, or request a prescription refill during that visit, it changes the nature of the appointment.
Here’s what happens: Your provider documents the services provided during your visit. These notes are used to assign specific codes to your care. When your insurance claim is processed, these codes determine how much of the cost is covered.
If your visit includes discussions or treatments related to chronic conditions, the billing staff may code your visit differently, potentially turning a preventive visit into a chronic care management visit. This could result in you having to pay out of pocket.
Preventive procedures like mammograms and colonoscopies are typically covered 100% when coded as screenings. However, if an issue is found during these procedures (e.g., a polyp removed during a colonoscopy), the procedure might be recoded as diagnostic. This change could lead to additional costs for you, especially for follow-up procedures.
So, what can you do to avoid unexpected charges?
- Understand the Process: When scheduling a preventive visit, know that your doctor will follow specific guidelines for the services that occur during a preventive visit. Make sure you understand what will be done during your appointment to avoid surprises.
- Schedule Separate Visits: If you need both preventive care and chronic condition management, it might be better to schedule separate appointments. Both types of visits are important so talk to your physician about your need for one or the other, or both.
- Review Procedure Results: After preventive procedures, check if any findings might change the nature of future procedures, potentially affecting your costs.
- Weigh the Costs: Consider whether the potential cost should affect your decision to have necessary screenings or procedures. Avoid skipping important tests just because there might be a charge. The risk of undetected health issues will cost you more in the long run.
Some health plans are considering covering procedures like mammograms and colonoscopies at 100% even if they end up being coded as diagnostic. This change would help remove financial barriers and encourage more people to get the preventive tests they need without a financial impact.
To learn more about how your health plan related costs are determined, check out my 3-part series on What Makes Up Your Medical Insurance Costs.
Written by Brian Mitchell
Brian has experience leading Total Rewards strategy and implementation for large employers.
Benefit Boosts by Brian Mitchell© – Vol 2024-013
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