When you visit your doctor, the Affordable Care Act (ACA) ensures that many preventative services are covered at no out-of-pocket cost to you. However, if you bring up a health concern or your doctor requests a service that isn’t covered under the ACA during a visit, different rules apply. And you will likely receive a medical bill after your appointment that you were not expecting.
In this blog post, I will share resources for learning what preventative services are covered under the ACA, what happens when you discuss non-ACA-covered services at the doctor, and key questions to ask your provider to clarify coverage so there will be no surprise bills after your visit.
Understanding Preventative Care Under the ACA
The Affordable Care Act (ACA) has transformed healthcare in many ways, making preventive care more accessible and affordable for millions of Americans. One of the key benefits of the ACA is its emphasis on preventive care, ensuring that people can access essential health services without out-of-pocket costs.
Preventative care refers to medical services that focus on preventing illnesses, managing chronic conditions, and identifying health problems early when they are most treatable. The ACA mandates that health insurance plans cover specific preventative services at no cost to the patient. Typically, the ACA covers the following types of preventative care services:
- Annual physical exams
- Blood pressure, cholesterol, and diabetes screenings
- Vaccinations
- Women’s health services (mammograms, pap smears, prenatal care, contraception)
- Children’s health services (well-baby and well-child visits, vision and hearing screenings)
- Mental health screenings
- Chronic condition management (obesity and tobacco screening and counseling)
You can visit the Healthcare.gov website, linked here, to see a full list of the preventative health services covered by the ACA. You can also review your insurance plan’s coverage details to understand what is covered and what isn’t. You can find this information in your plan documents or contact your insurance company directly.
What Happens if You Discuss Non-ACA Covered Services at the Doctor?
When you discuss, or receive care for issues that aren’t covered as preventative care under the ACA, you will likely be billed based on your insurance plan. Here is a real-life example:
Tom scheduled his annual physical exam with his Primary Care Provider (PCP). He’d been experiencing knee pain over the past few months and planned to wait to discuss this with his PCP during the visit. During his appointment, Tom mentions his knee pain and his PCP performs a knee examination. After the examination, his PCP prescribes Tom an anti-inflammatory prescription drug, orders a CT scan, and refers Tom to an orthopedic specialist. A month later Tom is surprised to receive a bill in the mail from his PCP for the knee examination. He was seeing his doctor for his annual wellness visit, so shouldn’t this be covered under the ACA? Unfortunately for Tom, the answer is no. Tom’s PCP performed a knee examination, sent in a prescription, and diagnosed the knee pain with an actual diagnosis code in the providers’ computer system. Tom was billed for the time spent discussing and treating his knee pain, which is outside the scope of what the ACA specifies as part of an annual physical exam.
Best Practices to Clarify ACA Coverage
The responsibility is on the patient to determine if the medical care you receive is covered under the ACA and your insurance plan. You can never assume something will be covered. But you can prepare for your appointment:
- Prior to seeing your doctor – Do your homework and research.
- Call your provider, tell them what you are going to discuss with your doctor, and ask for an estimate for any potential services and tests. Make sure to share your insurance plan details with your doctor’s office so they can check your coverage specifics.
- Check your insurance plan. Call the number on the back of your member ID card or go online to your carrier portal to review your insurance plan’s coverage details.
- When seeing your doctor – Ask the right questions, which can include:
- Is this service considered preventative care under the ACA?
- Will I have out of pocket costs (copay, deductible, etc) for this service or treatment?
- If there are out of pocket costs, when is payment expected and are there payment plan options?
Now more than ever, we each need to be an informed patient and take an active role in our healthcare. By understanding the preventative services covered by the ACA, how non-ACA services are billed, and our role in clarifying any potential out-of-pocket expenses, we make better-informed decisions about our health. Your health is your most valuable asset and investing time and effort in being informed is well worth it.
If you have questions about your coverage or receive a bill for a service you don’t recognize or believe was incorrectly billed, feel free to contact me. I am always happy to help! You can also visit the Employee Advocate page on our website, here.
Sara Closson
Employee Advocate
SClosson@AcadiaBenefits.com
Phone: 207.523.0065
Toll-Free: 866.761.2426
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