Take Advantage of Free Preventive Services
Today’s Health Insurance plans may offer benefits above and beyond just doctors and hospitals, such as free preventive services, fitness programs, teledoc/telehealth, and so much more!
Preventive Health Care
It’s Free and Can Save Your Life
If you are enrolled in an ACA-compliant health insurance plan, then you are entitled to receive a broad range of preventive services without cost-sharing responsibilities (money that you would have to pay), as long as the service is given by a provider within your health insurance company’s network. This coverage first began in the fall of 2010 for those who enrolled in a new health insurance plan. Starting in January of 2014, this requirement expanded to plans offered in the individual health insurance market, as well as small and some large group markets.
What’s The Difference Between Preventive and Diagnostic Care?
What Is Preventive Care?
Preventative care includes the health services you obtain to stay well and avoid developing life-threatening conditions. During a preventive care visit, your doctor may review your likelihood of developing a condition such as high blood pressure or diabetes and discuss what you can do to lower your risk. This type of care also includes routine checkups, preventive screening tests, annual wellness visits and most immunizations. The purpose of this type of care is to catch potential problems before symptoms develop. For example, a Colonoscopy is preventative, (unless there are polyps that need to be removed or other problems found) then the doctor will not bill the insurance for a preventive procedure but instead bill it as a diagnostic procedure. If it’s billed as “diagnostic”, you will then be subject to pay your deductible, co-pay and/or out of pocket maximum.
What Is Diagnostic Care?
Diagnostic medical care can diagnose, monitor, or treat existing problems. This may include following up on abnormal test results to further investigate a problem or treat certain symptoms. It may also include procedures such as removing moles, skin tags or treating back pain. As in the paragraph above, removing polyps during a preventive colonoscopy now makes the procedure not just an examination, but a diagnostic procedure. The polyps could be sent to the laboratory for further analysis to determine if anything is cancerous. All diagnostic charges will involve your deductible, co-insurance, co-pay, and/or out of pocket maximum.
The Type of Care You Get Can Impact Your Out-of-Pocket Costs
Your routine visit with your primary doctor may include preventive care and diagnostic care. While you may not notice much difference between these two care types during your visit, your doctor will bill the health insurance company differently for these services, and the health insurance company will pay for them differently.
Most health insurance plans cover certain preventive services at no cost to you, provided the doctor has billed the insurance company for “preventive services”. However, when you obtain diagnostic care, you will usually pay a deductible, co-pay, or co-insurance. Understanding the difference between preventive care and diagnostic care can help you know what to expect to pay for.
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Why It Is Important to Know the Difference
There is considerable overlap between preventive and diagnostic care, and it can be confusing to know which category a given service falls under. In some cases, a service may be categorized as preventive for one patient and diagnostic for another. For example, a blood pressure check that is part of a routine annual checkup for someone with no history or risk factors for high blood pressure is preventive care. On the other hand, it is considered diagnostic if the individual experiences symptoms such as chest pain, severe headaches or has a history of high blood pressure already in their past or present.
Many preventive services are covered under ACA-compliant health insurance plans at 100%, meaning the individual doesn’t pay a copay or coinsurance for services. For example, if you are being seen without symptoms or for routine yearly checks, it could be billed preventive. If you are being seen with symptoms, it most likely will be billed diagnostic.
Make Sure the Doctor’s Office Bills You Correctly
If you see the doctor for preventive services only, you should not see a medical bill. We suggest that if you go to see the doctor for preventive services, do not talk about or have any other services performed. This way, your No Cost $0 dollar Co-Pay preventive service will remain free, and you should not see a bill. Make sure to be careful to stay within your network for preventive care.
Before obtaining a test or service, it is helpful to talk to your doctor about why it was ordered. Knowing this will help you determine whether it will be preventive and fully covered or diagnostic causing you to have a cost-sharing responsibility. If you find you’ve been billed for something you thought was supposed to be preventive, find out from the billing department at your doctor’s office how they billed the insurance company.
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Covered Preventive Services for Adults and Children
There are four categories of preventive care that health insurance companies are required to provide coverage for without cost-sharing.
1). Screenings and Counseling
Health insurance companies must provide evidence-based screening and counseling services for adults. Covered preventive services for adults includes:
- Diet Counseling
- Obesity Screening
- Diabetes Screening
- Depression Screening
- Blood Pressure Screening
- STI Prevention Counseling
- Screening for certain types of cancers
- Screening for HIV and sexually transmitted infections
2). Routine Immunizations
Health Insurance plans must completely cover routine immunizations for kids and adults, including:
- Flu shots
- Varicella
- Rotavirus
- Hepatitis A
- Hepatitis B
- Poliovirus
- Human Papillomavirus
- Measles, Mumps, Rubella
- Diphtheria, Tetanus, Pertussis
- Meningitis (meningococcal and pneumococcal)
3). Preventive Services for Children and Teens
In addition to the recommended routine vaccines and health screenings, health insurance plans must also provide coverage for preventive services for kids and teens. This includes:
- Tuberculosis testing
- Blood pressure screening
- Oral health risk assessment
- Iron and fluoride supplements
- Hearing screening for newborns
- Obesity screening and counseling
- Alcohol and drug use assessments
- HIV screening for high-risk adolescents
- Behavioral and developmental assessments
- Height, weight and body mass index assessments
- Autism screening for children at 18 months and 24 months
4). Preventative Services for Women
Women with an ACA-compliant health insurance plan are entitled to additional services with no cost-sharing obligations. These include:
- Well-woman visits
- Cervical cancer screening
- Domestic violence screening
- Anemia screening for pregnant women
- Breastfeeding supplies and counseling
- Infection screenings for pregnant women
- Screening and counseling for HIV and STIs
- FDA-approved contraceptives and related services
- Gestational diabetes screening for pregnant women
- BRCA counseling about genetic testing for high-risk women
- Breast cancer chemoprevention counseling for high-risk women
Children (0-17):
Coverage includes regular pediatrician visits, vision and hearing screening, developmental assessments, immunizations, screening and counseling to address obesity and help children maintain a healthy weight.
Women (18-64):
Coverage includes cancer screening such as pap smears for those ages 21 to 64, mammograms for those ages 50 to 64, and colonoscopy for those ages 50 to 64, recommended immunizations such as HPV vaccination for those ages 19 to 26, flu shots for all adults, and meningococcal and pneumococcal vaccinations for high-risk adults, healthy diet counseling and obesity screening, cholesterol and blood pressure screening, screening for sexually-transmitted infections and HIV, depression screening, and tobacco-use counseling.
For plan years (in the individual market, policy years) beginning on or after August 1, 2012, additional preventive services specific to women, such as well-woman visits, screening for gestational diabetes, domestic violence screening and counseling, prescriptions, FDA-approved contraception, must be covered with no cost sharing.
Men (18-64):
Coverage includes recommended immunizations such as flu shots for all adults and meningococcal and pneumococcal vaccinations for high-risk adults, cancer screening including colonoscopy for adults 50 to 64, healthy diet counseling and obesity screening, cholesterol and blood pressure screening, screening for HIV, depression screening, and tobacco-use counseling.
Free Preventive Services:
From the Health and Human Services website and their partner websites, here are some examples of what is covered, without co-pays, co-insurance, or deductibles.
For Women: Women’s Preventive Services Guidelines
For Children: Recommendations for Preventive Pediatric Health Care
Getting The Most With Nevada Insurance Enrollment
Understanding your health insurance coverage is necessary to ensure that you are getting adequate health care service, regardless of your age and health status. To find a comprehensive health insurance policy and understand your health insurance coverage, contact Nevada Insurance Enrollment. Our agents can discuss your policy with you to make sure you understand what your policy covers.
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