Under the Affordable Care Act, many insurers are required to cover certain Preventive Care Services at no cost to the participant.  Even with media outlets running public service announcements on behalf of HealthCare.gov, so few participants of group health plans are aware of this benefit and/or how to exercise the benefit properly.

Health insurance plans beginning on or after September 23, 2010, account for preventative care in their plan descriptions. Eligible Preventive Care Services vary by age and gender, as do the recommended frequency of such services or procedures. 

To get the most out of this benefit — which you are paying for in the form of higher monthly premiums — and to ensure you are doing your part to get the desired results (i.e. healthier participants and early detection of serious health risks), it takes some individual responsibility and education.

1. Know the Preventive Care Services you and your family members are entitled to receive, at what age and with what frequency.
2. Make sure you stay within your plan network.
3. Advise your doctor, provider or scheduler at the time of making the appointment that you are scheduling a Preventive Care Service or visit.
4. On your bill, referral or physician’s orders make sure the procedure, service or visit is coded as “Preventive” and not “Diagnostic”.
5. Check your Explanation of Benefits (EOB) after the service is completed to ensure the claim has been processed properly.

Preventive Care Services must be covered without the participant having to pay a copayment or co-insurance or meet a deductible.  Some exclusions do apply.  Certain procedures may be considered diagnostic if a health issue is uncovered during the procedure or screening.

(Photo credited to weirdblog.wordpress.com)

DISCLAIMER: Because of the generality of this update, and based on particular situations, the information provided herein may not be applicable in all situations and should not be acted upon without specific legal advice, financial advice and/or the advice of a licensed insurance or certified human resource professional.

© Connelly, Carlisle, Fields & Nichols 2012