Due to the Affordable Care Act (Healthcare Reform), some important preventive services are covered at no cost to you, such as screenings, vaccinations and counseling. However, if there are any other tests, diagnosis or issues addressed at that visit, you may be charged for those services. Preventive screenings do not include disease monitoring or surveillance of a diagnosed condition.
What are Preventive Services?
- Well-woman Exams
- Well-child Exams
- Annual Physicals
- Family Planning
- Prenatal Services
What Services Are Included?
- Blood pressure, diabetes, and cholesterol screenings
- Many cancer screenings, including mammograms and colonoscopies
- Routine vaccinations against diseases such as measles, polio, or meningitis
- Flu and pneumonia shots
- Counseling on such topics as quitting smoking, losing weight, eating healthfully, treating depression, and reducing alcohol use
- Counseling, screening, and vaccines to ensure healthy pregnancies
What May Not be Included as Preventive Services?
- Asking for refills of a maintenance medication. The doctor will probably be willing to write you refills, but this is not a preventive service and you may be billed separately.
- Asking to have other ailments addressed (moles looked at, sore back or headaches diagnosed, etc). Again, not preventive in nature and do not fall under the government guidelines for preventive services. This will be covered, but you will probably have a co-pay or co-insurance due.
- New patient office visits. Often times if the physician has never seen the patient before, a complete history and physical is done and that would not be covered as preventive.
Claims are paid SOLELY on how your provider codes the services rendered during your visit. The health plans (all of them) are required to process the claims as submitted by your physician, regardless of any extenuating circumstances. For example: A well-woman exam is coded V72.31. If during that visit you ask to have your blood-pressure prescription renewed, the code would change to reflect the diagnosed condition. Accordingly, the well-woman portion of the visit (pap smear, blood pressure screening, etc.) would be covered at no cost to you; however, the additional coding for an existing condition may result in out-of-pocket expenses.
If a preventive screening exam detects a condition, the purpose of that screening remains preventive, not diagnostic, and there will be no charge. However, once a diagnosis of a condition is made, all future screenings for that condition will no longer be considered preventive, but are considered monitoring or surveillance of a diagnosed condition, with the applicable co-pay or coinsurance applied.