May 22, 2024

Because of the Affordable Care Act (ACA), one of the features of all ACA-compliant health plans is full coverage of preventive care at no cost to you.  Even if you’re on an HDHP or HSA-qualified plan, where most services are only covered after the deductible is met, all preventive care services from an in-network provider are covered 100%.

But what is preventive care?

Although one could argue that ANY medical care is preventive (“By stopping the bleeding, you’re preventing me from dying!”), the ACA’s official definition of “preventive care” is “Routine health care that includes screenings, check-ups, and patient counseling to prevent illnesses, disease, or other health problems.”  The main idea is that if health conditions are detected early by scheduled screenings, rather than after you’re aware of them, they’re easier to treat and correct.

The simple rule of thumb is: If you’re going to the doctor because of the calendar (“Hey, Doc, it’s time for my annual physical!”), it’s preventive, and 100% covered. If you’re going to the doctor because of a symptom (“Hey, Doc, can you check out this lump and make sure it’s nothing to worry about?”), it’s diagnostic, and subject to the normal benefits of your coverage regarding deductibles, copays and coinsurance.

Of course, nothing is ever as simple as a simple rule of thumb.  The U.S. Department of Health and Human Services, as advised by a number of advisory committees, maintains a list of official preventive procedures, which can be modified from time to time. In general, though, these services are divided into three categories:

  • For all adults. This includes a standard annual physical, common immunizations (both one-time, such as measles, or annual, such as influenza), hepatitis screenings, colorectal cancer screening for adults 45 to 75, STD screenings, etc. Most of these services are only cover once per year.
  • For women. This includes normal gynecological checkups, plus screenings for preeclampsia and Rh incompatibility for pregnant women. Again, most services are covered only once per year.
  • For children. This includes scheduled well-baby and well-child checkups, standard childhood immunizations, and behavioral assessments. Several of the services, especially for babies, are scheduled more frequently than annually (eg. quarterly).

Again, it bears repeating: These are almost all scheduled services, which you receive either on a set schedule (eg. annually), or upon reaching a certain age.  If, however, you make a doctor’s appointment because of a symptom or condition, that’s not preventive, it’s diagnostic, and as such will be covered however your insurance covers a normal office visit. That’s why it’s important to specify when making the appointment that you want to schedule a preventive visit specifically. And even then, if you’re getting an annual physical and say, “Hey, Doc, while you’re at it, I’ve been getting pains in my ankles…” BAM. You just changed your visit from “preventive” to “diagnostic.”

And what happens if you’re getting a preventive screening and the doctor finds something?

Then the diagnosis and treatment will be covered as standard procedures, not as preventive care. That may sound like a bait-and-switch, but if the doctor finds a condition early enough that you hadn’t noticed any symptoms from it, it could be the difference between treating a small problem with simple procedures or medication vs. finding out only when it’s a systemic issue that requires massive invasive treatment. That’s not a bait-and-switch; that’s a demonstration that the preventive care system works.

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