As a professional in the healthcare insurance industry, I have access to terms and conditions of care that most people don’t know. Recently, I have been asked to assist clients in deciphering when care is ‘preventive,’ covered at 100% by your health plan, and when it is not considered preventive.
Just because you go to the doctor for a check-up does not mean that everything that your doctor does or orders is going to be covered at 100% as preventive. If there are procedures provided during this visit that are not “preventive” as defined in the list below, then the service is called routine or the procedure is of a “diagnostic” nature and will NOT be covered at 100% just because you had it during your annual preventive care exam. If it’s not on the list, it is simply not covered for “free.”
What is the simple answer to “What is preventive care?” Preventive care is:
Blood Pressure, diabetes and cholesterol testing
Screening tests for common cancers, such as mammograms and colonoscopies
Counseling for smoking cessation, weight loss, healthy eating, depression treatment and alcohol consumption
Routine vaccinations like measles, polio, meningitis, flu, pneumonia and shingles
Healthy pregnancy screenings, vaccinations and counseling
Regular well-baby and well child visits through age 21.
For the most part, this is exactly what preventive care encompassed prior to the enactment of PPACA. Currently, you can also receive HIV, syphilis, and sexually transmitted infection screenings. In addition, certain men receive Abdominal Aortic Aneurysm screenings.
Some of the items that may be included in a regular check-up that are not covered at 100% as preventive include Vitamin B-12 deficiency and Vitamin D screenings, anemia testing for males and testosterone level screenings. One big ticket item that many physicians like to include is an EKG. These have been deemed not necessary and are no longer covered as preventive in nature.
When you go in for an annual physical, it is wise to ask what screenings are included in your annual preventive care visit. Your doctor should have a list available for you of the tests that are standard, recommended testing and then patient-specific, which are tied to your medical history. This step enables you to secure an estimate for the cost of any affiliated testing that is not defined specifically under the preventive care guidelines.
In my personal experience, my doctor’s office does a great job of explaining to me what is being done, what is covered 100%, and what is not. Ask the same from your physician.
The last piece of my infinite wisdom: make sure that your annual preventive care exam is scheduled at least 365 days after your last preventive care exam. If it falls on the 365 or prior, it isn’t considered annual!
Heather Slinkard has more than 20 years of experience in the human resource management field working with employee relations, benefits, payroll and management. She has been with Lawyers Insurance since February 2007 working exclusively with the NCBA Health Benefit Trust. Contact Heather at 800-662-8843 or firstname.lastname@example.org.