May 01, 2019

Preventive care is covered 100% by health insurance…but what exactly is it?

By The IBX Insights Team

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By now, many consumers know that health insurance plans are required by law to cover 100 percent of the costs for preventive care. However, a question we often hear is, “What is preventive care?”

Preventive care is the care you receive to prevent illness or disease. It also includes counseling to prevent health problems. Providing these services at no cost is based on the idea that getting preventive care, such as screenings and immunizations, can help you and your family stay healthy. Preventive care may also help reduce your health care costs down the road if you catch a problem early, or if an immunization keeps you from getting a serious illness.

Here are a few examples of what’s covered, plus tips to help you know what to expect. Preventive care services include:

• Wellness visits and standard immunizations
• Screenings for blood pressure, cancer, cholesterol, depression, obesity, and Type 2 diabetes
• Pediatric screenings for hearing, vision, autism and developmental disorders, depression, and obesity

There are also certain recommended preventive services and immunizations based on your gender and age. Check out the full list of preventive care services.

Is there ever a chance you might have to pay?

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Many preventive services are 100 percent covered by insurance. For example, if you have an IBX plan, you won’t have to pay anything for these services if you see a doctor or health care professional within our network.

There is a chance that you may still be asked to pay after a visit for additional services, so be sure to consider the following:

It’s important to make sure that you and your doctor are on the same page. Always ask what services your doctor is providing. What you pay will also depend on how he or she bills your health insurer.
If a preventive screening uncovers something that could be serious, your doctor may order additional tests, schedule a follow-up visit, or refer you to a specialist. The additional tests and follow-up may not be 100 percent covered.
If a preventive screening uncovers something that your doctor says needs to be addressed right away, then that visit may switch from being considered preventive to treatment. Also, if you see a doctor to diagnose, monitor, or treat an illness or injury, the visit is not considered preventive care. In these cases, your normal cost-sharing would apply (copayments, coinsurance, or deductible).
There may be limits on the number of preventive services you can receive with no out-of-pocket cost. For example, in some plans, a wellness exam may be 100 percent covered once every other year. However, if you get a checkup more often, your normal member cost-sharing fees may apply.

In any case, it’s always a good idea to check with your insurance company ahead of time on the services that will be covered.

What If you are charged for a preventive care service?

Be sure to keep your paperwork and bills handy. If you’re charged for a service you believe should have been 100 percent covered, here’s what you should do.

Check with your doctor’s office. Ask what services were billed to the insurance company. Does it match what you remember from your visit? If it turns out there was a mistake, the doctor’s office can send a corrected claim to the health insurance provider.
Check with your health insurer. Ask what services the doctor’s office billed. Does it match what you remember from your visit?
Ask your doctor for a reimbursement. If your doctor agrees that a mistake was made with your bill, ask your doctor to reimburse you the appropriate out-of-pocket expense.

This content was originally published on IBX Insights.