What Exactly is covered under Preventative Care under Obamacare?
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If I have a standard annual physical as a man aged 53, am I charged for the lab work on my urine and blood drawn? Such as lab test for PSA for prostate cancer? Such as cholesterol testing? Is the only thing that is free the actual doctor physical exam? It is all part of the annual preventative care visit, so it should all be covered, no?
Similarly, for a colonoscopy, the preventative care coverage under Obamacare means that the doctor is covered. What about the exam center? Is it covered? What about any anethesia and anethesiologist? What about the prescription liquid stuff I have to drink before to cleanse my colon? What about the initial visit to the doctor before my procedure?
Virginia
My son has a colon problem which requires a colonscopy every year. He says the premium is $9000 for this preocdure. What does Obama care cover.
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M. Pearce
Are echocardiograms covered under preventative care?
ObamaCareFacts.com
There is a list of preventive care, it is pretty specific and limited (like should be on this page already, but here it is clearly https://www.healthcare.gov/preventive-care-adults/).
“Echocardiogram” isn’t specifically on the list, but that doesn’t necessarily mean your insurance won’t cover it (or even consider it preventive care). There are two things to check here 1. check with your doctor to see if they would recommend it as such, and 2. check with your insurer to see how they would bill a claim given the doctor recommendation.
That basically goes for any service, but of course also applies here.
Ultimately it is your insurer who will accept or deny claims based on your health plan and your doctor who will coordinate and recommend care, and often how to insurer processes a claim depends on how your doctors process the claim and handle the referral process.
Carva
So only shoving the tube up your butt is free, everything else involved in the colonoscopy procedure isn’t. That’s like saying the steak dinner is free, you just have to pay the waiter, for the plate it’s served on, the chef’s time, etc etc.
Only in America.
ObamaCareFacts.com
It is a bit more generous than that, but the way it works 100% lends itself to this sort of teasing (as there is some truth in it).
H Gordon
I’d like more detail as there are other type of preventative care services. I.E. Preventative Care for BC – IUDs, I’m trying to determine what is covered. The initial doctor’s visit has a $40 co pay but is the lab covered where the IUD is from? One goes to a doctor for an appointment, the doctor sends work out to a lab (you never go to the lab), is the lab work covered as well?
ObamaCareFacts.com
Things can get so complex here that I know ALWAYS suggest one call their insurer. Generally the preventive care is covered, but other things like lab work and visits might not be (there are multiple factors at play here, including if the care is considered preventive or not; the same exact service can be preventive or not depending on the circumstances).
The insurer is a great first line of defense here because they will explain how the ACA works AND how your plan’s cost sharing works.
With deregulation coming up I am very hesitant to give overly specific answers on the matter.
For birth control, see: https://obamacarefacts.com/obamacare-birth-control/
… but keep in mind, these are the “essential health benefits” in the cross hairs of those who seek to “repeal and/or repair” ObamaCare.
Stephen Ashton
what a joke, I feel like I’m shopping for a set of encyclopedias
ObamaCareFacts.com
Well said. There is room for improvement here for sure.
Carmela Lewis
The cheapest plan I can find for my husband is $399.00 a month with a Deductible of $4000.00 a year before ANY coverage is paid including medications then at only 50% coinsurance . Our annual income is above the Obamacare limit for assistance But still how is that “affordable” when nothing is paid for? Only Annual Wellness but no lab work.
Mary Mille
Question: are my yearly EKG’s covered as ‘preventative’ screening. My doctor includes this test as part of my yearly complete physical. I have Emblem/HIP/VIP, and as of 2017, there will be a co-pay for certain tests that were no-cost up until next year. The EKG is one of them. Please respond using the email below. Thanks, Mary Mille
Charles cyr
Are these test cover free screening Lipid panel. Metabolic panel. PSA screening
Mike
I had a screening colonoscopy performed 3 years ago. A single polyp was removed. The gastroenterologist recommended another procedure in 3 years. It appears future procedures will be coded as a “diagnostic” procedure and subject to a “cost share”. This is a disgrace. It is nothing more than a sleight of hand to shift the financial burden away from insurance providers to consumers. The intent of federal legislation was to encourage consumers to have this life-saving procedure.
I read the federal government clarified that high-risk patients could qualify for more frequent screening without cost sharing. Can you expand upon that or link the source where that is explained?
[email protected] Erin
Thank you for your question. I have found a little more detailed discussion specifically about preventative colonoscopies coverage. It discusses what is covered, how to ensure it is billed correctly, and why legislators wanted insurer’s to cover it. You are right that often the under lying problem is that Private Insurer’s often try to find ways to avoid actually providing coverage. It’s ultimately that behavior which the Affordable Care Act was trying to address. I hope that you find the information you are looking for and I will also forward this resource over to the writer so we can make sure we cover this topic more completely here on ObamacareFacts.com.
Norman
Apparently these other charges effectively make getting a physical not free at all. So much for preventive care. So why not be clear and say annual physicals are not free.
Mandee
This is all well and good for people over 50. I guess I can just pay for everyone and wait 11 years before i qualify for many of these additional benefits. Sweet deal
Gail
The first thing that must be done is to define the word “free” in free preventive care. To my horror doctors and insurance companies have a different meaning to “free”. Still have not figured out their meaning. Mine is simple and is understood by all, if it is free I do not have to spend my own money. I also thought that if I had prior approval, the test would be paid for. This proved to be untrue. I find that when I go to the doctor it is impossible to budget money for payment because I am never sure what I will have to pay. Thirty years ago I would know because I would receive a full statement listing all test and expenses; after paying the deductible (usually $100) I would be responsible for 20%. If it is very large I can pay monthly until paid in full. Not today. I never know how much I will have to pay and they expect payment in full, no monthly payment. Any question why I no long go to the doctor. All trust has been destroyed.
Clifton Sanchez
Great info!
Mira Taylor
My kids are covered by Medicaid.Do we need to pay for their physical examination as one of the requirements for school admission?
Jean Guanchez
Is an annual PCP or annual GYN office visit covered under these plans BEFORE deductible is met?
Are Urgent Care office visits covered BEFORE deductible is met?
Bob Johnston
There is too much confusion on minimum requirement vs what insurance companies want to compete on. If only a lipid lab test is covered 100% then insurance is interpreting as complying with minimum onlly. Why did we not go to a single payer system? Because of insurance companies wanting to compete in the market. However, they are not and since other tests like metabolic and urinalysis are not covered by many physicals any longer the insurance CEO’s lied and are still increasing premiums with less preventive care. You will be shocked on what was covered in 2010 vs what is now covered in 2016. Pathetic. Only a lipid test? Insurance companies can still compete if they listen to the physicians on what a physical Should Be! Instead now we have all providers biting their tongue or quiting primary care. Come on insurance companies, start competing for group plans by adding back the diagnostic labs that are very low cost to the group members that pay already outrageous premiums. The market will dictate. A good example is blink health. Bypassed the PMC for prescriptions and I bet Lab Corp can set up a similar easy to use lab app so patients can skip the money mongers and greedy insurance companies. This is the only option until a medical revolution occurs in the next 4 years. It is on it’s way since the market left the door wide open.9
EWM
Since signing on to Obamacare, literally every family and ortho doctor I had has dropped me, my premiums went up $350, the deductible has doubled to over $6,000, and my last two Obamacare insurers in South Carolina have (or will next year) have gotten out of the market. Why am I not surprised that there’s so little coverage for that preventive care I heard so much about.
jay
I am a 34 year old male who was diagnosed with Ulcerative Colitis 10 years ago. Due to my greater risk factor for getting colorectal cancer my Dr. has informed me that I will have a yearly colonoscopy procedure for the main purpose of preventive colorectal cancer screening. Seems like a wonderful preventive procedure exam that I am fortunate to receive. However thanks to Obamacare I am punished with over $500 in out of pocket costs for the preventive procedure just because I have a pre-existing condition and it is now termed a “diagnostic procedure”. How does that make any practical sense? Next year I will have to make the decision do I do the preventive procedure or do I decline it because I can’t afford it. Thanks Obamacare for making all those who suffer and struggle from pre-existing conditions on a daily basis suffer even more where it hurts the most, the wallet.
Melany Granville
I don’t see the answer to the question. This information would help me too. If a person gets an annual physical is the lab work covered at no charge? For example, the lab work for having blood drawn for cholesterol check
ObamaCareFacts.com
You have to check with the insurer. As a rule of thumb preventive tests are going to be covered, and this could certainly include lab work (it was true for me on all but one test for instance), but it is a little complex and thus checking with the insurer is the right move. When the doctor and the insurer know your motive is to get your free wellness visit and free preventive care they can help organize your care in a way that you will incur minimal or no fees.
lily
Wow….that leaves so much out. I’m apalled at how shotty Obama care is.
Susan Lucchesi
AND, what about women? Most major medical clinics have online services that will send a patient yearly reminders for preventitive procedures/tests so what is the point of going in?
An annual physical is different for every individual. For a person w chronic conditions it may be preventative to f/u or make changes in regimen of care. This is preventative to maintain health and avoid complications and further need for costly or life threatening conditions.
Mary Martin
Is an Echo Stress test covered as part of screening with annual check up?
ObamaCareFacts.com
I’m not sure. Always best to check directly with the insurer. They will give you the correct information (one good thing about regulation).
Jack
Obamacare sucks!
Pdo
no prostate or testicular related cancer screenings…..add them!!!!!!!
ObamaCareFacts.com
I think they are covered, maybe they are listed under a technical name. Generally preventive screenings of that nature are all covered. You can ALWAYS check with your insurer for clarification.
NH
You keep saying check with your insurer, but there are no consequences for them when they lie.
Kaiser told me a routine eye exam is covered under my plan and then slapped me with bills afterwards. I appealed with no luck. Now I have to appeal again with the state.
ObamaCareFacts.com
Hmmm. Well I am aware that things can get complicated. You can check out your summary of benefits and coverage, and you can check with your insurer, and you can check with the insurer.
Furthermore, we have a full list here: https://obamacarefacts.com/obamacare-preventive-care/
With that said, it is even more nuanced then this (as parts of a service can be covered and parts not, like a drug). Because it is detailed like this we say “check with your insurer.”
You say “the insurer can lie”… but I don’t think they can really get away with that. If they say “we cover it” and then they don’t, I feel like that is groups for a successful appeal. I’m surprised that didn’t work. Did you escalate? If an internal appeal fails you can generally escalate to an external appeal.
Hope that helps.
Jennifer Bruce
I have dense breast tissue which means that the results of a mammogram will always be inconclusive and require a sonogram or ultrasound. Thanks to Obamacare, my “free” mammogram now costs me around $150. Same for what were once considered routine “preventative” blood screening tests. They are now considered diagnostic and not preventative. Free annual checkup cost $240!
This does not encourage patients to visit the Dr. for “preventative” care which will ultimately cost the insurance companies big time when problems are not caught in a timely manner.
NOT happy.
ObamaCareFacts.com
Thank you for sharing, this is a very real problem that needs addressing. The idea that the ACA is perfect is debunked best by real experince from those who sincerely struggle under the law.
Donna Harmon
Under the Obamacare you no longer get blood work that pays for Thyroid, Diabetes & many other preventative conditions.
[email protected] Erin
The Affordable Care Act expanded what insurers are required to cover at no out of pocket costs. Prior to the law, there were NO preventative care or blood work required to be covered at no out-of-pocket costs. Diabetic Care is also included on the list of required preventative coverage.
Debbie
What about Mamograms for wemen, What is covered under this
ObamaCareFacts.com
Absolutely, preventive mammograms would be covered, but you need to check with the insurer / doctor for details (that is the hard and fast rule for all questions on here by the way).
Michael
My Platinum plan premium has risen from $185 in 2014 to $121 in 2015, now it is $270; the deductible went from $5,500 to $6,000 now $6,500! I don’t get the Federal subsidy because my spouse and I make too much money (but hardly). My question is why would a person want to earn more money in a paycheck only to have to pay it to an insurance company when the government is paying him $5,000 or more in Federal subsidy? Doesn’t the OBAMAcare system reward the unambitious and encourage making less money to get $5,000 or more for free?
ObamaCareFacts.com
It doesn’t work exactly like that. So to get the government to give you a $5,000 tax credit you have to be just the right type of working poor. If you are below you get Medicaid and the tax payer only pays for what is used. If you make more, you are closer to the same situation you are in.
That said, a person works hard because… Their parents raised them right? Or they have self respect? Right? I’ve never spent too much of my time thinking about the type of people who would purposefully not work, so perhaps i’m missing something.
I think we all get a little annoyed at income tax, payroll tax, fees, debt, etc. And health insurance just feels like another bill a lot of the time. But when it comes to crunch time it is really important to have.
To your point though, I agree, assistance programs that incentivize not working need a closer look, and I think that is an implication that needs to be considered carefully when passing legislation.
Jack
No we pay for all the illegals, leeches and welfare losers who could get a job but under Obama there are no jobs and the healthcare keeps going up it will crash our economy needs to be repealed!
Mike
Yes. And also don’t work. The government mentioned will take care of you with welfare and free phones!
ObamaCareFacts.com
Yeah all that welfare and free phones, finally someone taking on the real issues. Yeesh. Who cares who gets to eat dinner and own a cell phone, I’m uncomfortable with the idea that any American family would go without these things.
That said, I’m always for a reward for hard work over a handout. And we have to make sure that is the attitude in congress too. Speak with your vote.
Kathryn Warren
If a person has a DNA diagnosed disease, the required screenings to determine if and how the illness has manifested itself will be covered as preventive or diagnostic? Clearly the screenings are meant to detect problems before they become giant problems, and are preventive in that respect. Why is Cigna not covering them as preventive?
ObamaCareFacts.com
I can’t answer this for sure, at that point it gets into doctor / insurer coding territory. If you don’t like one answer, try asking the other for help clarifying it.
deanna
My insurance is blue cross and blue shield.the company had people brought in Dec. Of 2015 and did a blood vial for a 36 panel test this test was to lower my yearly premium. My question is even tho there was findings or abnormal readings am i still entitled to my blood work under my wellcare anytime in the new year of 2016
od work under my well care
ObamaCareFacts.com
Once something is a known problem it is no longer “preventive” so the answer would likely be no. Always direct questions like this to your insurer.
gary roller
from reading comments, Colonoscopy I just had performed at Saint Louis university hospital will cost me hundreds of dollars at the least.
I asked and was told obamacare would take care of it. sad, for the doctor bill alone as over 200 dollars
Obamacare has added significantly to my bills in the past, why should I have expected different?.
ObamaCareFacts.com
Would be great if you came back with some details on the billing and claims aspect. Don’t forget you can appeal all healthcare decisions, sometimes it is by the book, but it is possible a doctor or insurer may miss something.
Jenal
I just discovered that the screening colonoscopies my husband and I had scheduled are potentially 100 percent uncovered if they find anything abnormal. This is a minimum $5,000 in unanticipated and unaffordable costs given the high cost of our premiums as middle class self-employed individuals. So preventative is not free, healthcare costs are not manageable or predictable, and ACA has proven to work in the interests of the corporate “people” who funded Mr. Obama’s election campaign rather than the real people who voted for him, like me. Where else and for what other product do you have to commit to spending before you know how much something costs? I have done the math, and between taxes, premiums, deductibles, dental and vision care, our percentage of income for taxes and healthcare would exceed 50% of our gross income if we met our annual out out-of-pocket expenses. How is this better than socialized medicine where citizens actually get something for their money? For us, there is only one option as we can’t afford the unknown cost and risk that our colonoscopies and related costs won’t be covered. We have cancelled our procedures and will deal with the cancer if and when we get it. If we continue down this path, I predict an increase in mortality rates on par with developing nations. For me, it’s simple: Illness-for-profit doesn’t work nor does any system that capitalizes on human misery and suffering.
Chet
Your post is spot on.
I just canceled my colonoscopy; I had an initial screening done 3 years ago which found a couple of polyps, so they wanted to schedule a re-screening after 3 years.
Was just told that my portion of the procedure would be $2250 – that does not include the doctor, anesthesia, or the prescription beforehand.
$2000 deductible and 40% co-insurance on top of a $600+ monthly premium which only covers me, and not my unemployed spouse. Had to get a separate policy for her with a DIFFERENT provider at $450 per month.
I don’t know what the answer is, but this system just sucks. Period.
Jan
As a woman – do I get an annual well woman visit with my gyn AND an annual preventative care visit with my primary care doctor?
ObamaCareFacts.com
Good question. You get a free wellness visit and free preventive screenings, but I don’t have an exact answer. Here is general advice. Screenings would typically be part of your well woman visit with your primary unless specifically noted as a free services here https://www.healthcare.gov/preventive-care-women/. The best bet on your behalf is to check with your insurer for direction (and doctor). This way you ensure any preventive service is at least a “covered services” and if it’s available as a “free preventive service” is covered. A lot of OBGYN services make it on the free preventive services list, so it would make sense, but it’s always smart to clarify with the insurer there can be instances were some parts of a visit are covered while others aren’t.
mike
Its another scam in ObamaCare. Nothing is free. If you go to into annual exam and mention “anything” pre-existing they can switch the code and charge you. Same with the supposed free colonoscopy. It is ONLY free if they find “NOTHING”. However, any dr. worth is salt will find something even if it later on proves to be nothing. So EVERY FREE COLONOSCOPY will have a charge. We were lied to folks…if you are just figuring that out now.
ObamaCareFacts.com
Well, it’s a matter of wording. You are right saying “free” and “keep your doctor” is not cool, it’s politics and not laser-pointed accuracy. But the president is there and some services really are free (I’ve personally accessed them). Get a good relationship with your doctor and ride your insurer if needed.
Jessica Richter
I find the fact that an insurance company can charge for a colonoscopy if a polyp is found absurd. Ditto if one is age 50 and has a slight finding of anemia or stomach issues. Who doesn’t have some symptoms in this society? I used to support Obsmacare but I am personally being taken to the cleaners as a self insured person with some income. It’s good that I cannot be denied insurance for pre existing conditions but the price tag for medical care and insurance pricing is the real problem
Laura
For a Diabetic under Obama Care he has to have blood work done 2 to 3 times a year. Will this be covered under preventive care? Insurance is doubled this year and if not covered under preventive care we cannot afford to have to pay the deductible before having labwork done.
ObamaCareFacts.com
So preventive services are covered, treatment for a preexisting isn’t free. Rather it should be covered as an essential benefits under your plan’s cost sharing structure. Generally, you should be looking at how this is covered when shopping for plans so you can get the best overall value out of your coverage. Consider an HSA and a Silver plan if you don’t know which direction to go. That is only very general advice though, every person’s needs are unique.
brian
No providing equal covered services for men as women is textbook discrimination. But discrimination against men is acceptable, right?
ObamaCareFacts.com
By your logic getting all my nieces and nephews a present on my nieces birthday is discrimination. At what point do we factor in morality and what it means to be an good American.
Mark
Clearly Obamacare is crap in all regards. Even my coverage under COBRA was very much superior to this mess that has been created. My premium has increased by about 25% even though I dropped down from a Silver to Bronze plan and now have a 6000 deductible with no prescription drug coverage until my deductible is met. I will not meet my deductible unless I have something very bad happen. Obamacare is simply catastrophic coverage at a much higher price. The health coop created by Obamacare has failed in my state, about half of them have already failed nationwide – more to come next year, costing taxpayers millions in loans that won’t be repaid. I very much hope that Obamacare is not repealed, but rather fails on it’s own. It’s almost there now. There will be more outcry in 2016 when employer plans are impacted. Watch for the democrats to try to exempt Cadillac plans for unions in order to keep their votes for Hillary. The tax on Cadillac plans was merely a sham to make it look like Obamacare would not cost so much. We were lied to sooooo very much. It just took this long for most people to realize it. Of course the whole problem could be fixed with a nice big government single payer system. Just like the VA and we know how well that works…..NOT! Venting off.
Terry
Beware this is not the case. I asked in advance if my colonoscopy would be covered, or if partial. I was reassured by my insurance company it was 100%. My treatment center confirmed it was 100%. It’s now been 4 months since the procedure and the bills are still arriving DENIED! Same thing happened to me on my annual check up. (I pay 500.00 per MONTH premium and I can’t even be screened for preventative exams with out incurring 1000’s in “Co share”. Another reason we live in an OBAMAnation!!!
ObamaCareFacts.com
What?! A preventive screening or wellness visit is covered on all major medical plans sold to individuals and in the small group market since 2014. If the service wasn’t preventive you could have gotten billed, or if you are on some evil grandfathered large group plan maybe. But this is really, really, really, not Obama’s fault in this case. Make sure to appeal your insurer and get to the bottom of this. Certainly don’t pay that bill without fighting it.
brandon
it probably isn’t covered because he is out of network. Same for me… I have been buying my own insurance on the open market for 15 years…. everything was sailing along good till this Obamacare came along. now I have to buy insurance thru an exchange just to get it to only double what I was paying the year before obamacare came along.Just got an annual physical last month….. obamacare will not pay because that doctor I have been going to for 20 years that I was suppose to be able to keep is out-of-network!!!!!!!! So save me the all the people it has helped bull!!!!!!!!!!!!!!!!!!!!
[email protected] Erin
Provider Networks are completely dependent upon the Insurers. This was the case before the Affordable Care Act and is still the case today. Private insurers create their own network of providers, can change those providers, and have any requirements they want for providers to be included in their network. The Affordable Care Act did not change that. If you are having a problem with the size of your insurer’s network or the costs for using providers out-of-network, you should call them or choose a different insurer.
NH
Same here- billed for a urine test when I went for a well woman exam. I had no complaints during the exam was clear that I wanted the preventive, free exam.
Called them about it many times. They told me I have the option to appeal in writing.
Bruce Phillips
It did not answer the question which is ” Are annual EKG’s covered under the free wellness screening in an annual wellness physical?
ObamaCareFacts.com
I think EKG’s would be covered with cost sharing as an essential benefit, but not as a free preventive service. (This is true for Medicare wellness visits and likely then true for non-medicare coverage).
Curtis
As noted in the comments, the answer to the question seems vague. It sounds like free is not really free that it all depends on how the Insurance and/or Doctor submit and process the claim. Not sure how anything really changed for most people you still are arguing with the insurance company just like pre-Obamacare.
Question:
If blood tests are covered can the insurance or doctor force you to use specific Labs? With my current insurance I can not use the Lab in the build where my doctor is, I have to drive to another facility.
Also I currently take Simvastatin I think that is supposed to be free but I pay for some of it. Are statins covered under Obamacare?
ObamaCareFacts.com
So to be clear, we do agree with you to some extent and any vagueness in the answer is unintentional.
On the surface the free preventive services seemed much simpler than they are in practice. For sure, the preventive services on the list are all free with any compliant plan. But, related services and getting those same services for non-preventive reasons can be subject to cost sharing.
As for the question on labs, the lab you would use should be determined by your plan’s network. You shouldn’t be forced by a doctor to use a specific lab that say wasn’t part of your network.
As for the specifics beyond this, given that it is all more complex than a blanket answer, the best bet is to check with the doctor and insurer to understand what is covered before accessing a service. This is probably one of those provisions that needs another round of reform. It’s well intentioned, but seemed to have left a few too many holes and points of confusion judging by the feedback on this thread and in other places.
Anyone with more information, specifics, or an exact answer to the above question would be appreciated and welcome.
Phil Stein
Why is my plan showing a cost for the doctor for colonoscopy if “screening” is covered. Anesthesia and facility are separate.
ObamaCareFacts.com
That is a really good question. Remember if something doesn’t seem right you can always appeal the insurance company about it. You can also just call and ask them to explain and let them know you assumed it would be covered based on what the plan showed it covered. In truth there are exclusions that, as you can tell, you are not alone in being frustrated with. Still, every person should do their own personal pushback and make sure their plan is covering everything it should. Sometimes you’ll end up having to pay for a service, but sometimes you’ll catch something the insurer didn’t.
Bill Bellegia
Why isn’t prostate screening covered as part of your preventative care list for men? It’s one of the most common cancers that men can get and it’s not on your list. If a man mentions that he wants a PSA test done as part of his blood work during his office visit, he is charged for the office visit because it is not on your list of covered screening topics that can be brought up during the office visit? Obamacare better make some changes!!! This is ridiculous.
ObamaCareFacts.com
Couldn’t agree more, the PSA test blood-work isn’t covered (but other related stuff is). Someone needs to take a better look at the free preventive services included on plans, with the high deductibles and loopholes for uncovered costs it’s hardly optimal as it stands. The idea is to prevent further healthcare spending by addressing important preventive issues.
brian
PSA screenings aren’t covered because the HHS doesn’t want to detect “potential” cancers in men. The detected cancers will need to be treated which cost money.
ObamaCareFacts.com
Pretty heavy conspiracy theory. I doubt this is true as a blanket statement. There is so much profit in treating chronic illness the incentive must work both ways. Probably a more “benign” reason.
Christy
If this is true, then why give women free mammograms and PAP smears?
cindi lee
digital rectal exam is covered under “preventive care” and it is the digital rectal exam that is considered to be more useful in screening for prostate cancer. the psa has LOTS of false positives.
for example, just a benign prostate hypertrophy, medications and normal hormonal fluctuations can cause increase in psa. if patients are regularly screened for increase in psa, and therefore, have to follow-up with other specialized (and more expensive) tests and biopsies, then there’s more risk of harm than benefit.
i hope this helps to clarify…
i’m a medical student.
Michael Falta
It seems that you cannot be too specific in your answer to this question because the response is partially dependent on the actual coverage you have. I will be needing my first preventive colonoscopy soon and now know I can expect to pay for some part of the procedure, depending on my actual insurance coverage. It is surprising that components of the preventive procedure that are absolutely required in order to perform the procedure are not in fact, fully covered under Obamacare.
Covered preventive services seems to be more of a moving target than one would think unless you dwell deeply into the specifics of the law. For example, my daughter received injection 1 of a series of immunizations at her well-child visit, and everything was covered. However, while injection 2 was covered several months later, we were charged a co-pay for the office visit when she got the injection. This makes no sense to me, but apparently is the case.
ObamaCareFacts.com
As someone who has studied the law and wrote about it extensively the free preventive care is probably one of the most frustrating aspects of the ACA. It’s not the intentions of the law or even how it is written, it’s how this specific provision works in practice that is lackluster. It’s unfair for what is and what isn’t covered to be such a grey area of technicalities, coding, and appeals. Certainly further reform needs to be taken in this area to simplify and clarify, there are simply too many complicated loopholes for the average American to navigate (let alone the cost in time to providers and insurers).
As for you as an individual what you want to do is talk to the doctor and the insurer first, coordinate what needs to be done and what will and won’t be covered. This way you’ll know what you are getting yourself into and your doctor can help ensure your maximizing covered services and avoiding services that are uncovered or will require lots of out-of-pocket spending.
Briana L. Cartwright, Esq.
If a Fire Rescue Department provides free mandatory annual physicals would that satisfy the “free wellness visit.” Does the free wellness visit have to be included in the health plan? Why or why not?
ObamaCareFacts.com
Good question, we don’t have an exact answer, but it could very well satisfy the mandate. Some large group plans and grandfathered plans are exempt from the new rules. So it could be a grandfathered or large group plan electing to offer this coverage. You can always ask for clarification from your employer.
C. Foree
My retiree health plan is not covering my annual screening mammogram. They are allowing 70% of the UCR cost and applying it to my deductible. Repeated conversations with the insurance company and my former employer have only confirmed that the correct coding was used for a preventative screening, however my former employer claims to be exempt from the ACA. Can you explain what types of policies can claim to be exempt from the ACA? This seems to be the key to the issue but repeated phone calls have not gotten me any kind of answer, much less a satisfactory one.
skye
Honestly it depends on how the Dr codes it and what the insurances conside medically necessary. It’s a thin line because insurances wI’ll male it tricky and deny coverage over certain things line an ekg or anything they cam get away with not paying by adding extra rules.
Phil
Agreed…I am looking at my cigna cost estimator for colonoscopy and it shows a few hundred dollars to primary physician who is doing the “screening” which is the one thing that is supposed to be free. I understand the other stuff…facility, anesthesia, etc has cost sharing, but the article above say screening is free. So what am I paying the doctor doing the screening for?
ObamaCareFacts.com
If it’s a preventive screening then you don’t pay. If you know you already have an issue, it may not be being billed as preventive. So that is another factor to factor in. Make sure to use your appeal rights and to call and question the insurer when appropriate.
Anita
But it is too complicated an answer. Think I want to know if I am better off under ACA,which people are and how much is the Cadillac plan?
Justyn Davidson
Is a simple physical exam covered? For instance, the kind of exam required to make sure one is able to perform physical activity? General physical exams are often a requirement of jobs or programs – I don’t see any language about this here.
ObamaCareFacts.com
You get a free wellness visit each year which is a preventive visit / check-up / physical. You would probably have to pay your copay / coinsurance on an additional physical exam if you already got your free visit. But if you haven’t got your wellness visit you would simply make sure your doctor was coding it as your preventive exam (always want to double check the doc is coding your treatments in alignment with what your insurance covers).
Paul Ness
This answered my basic question as to why I was billed for an EKG and blood work as part of a physical exam. It was surprising since these was previously covered under a high deductible plan.
Still unclear about what might or might not be covered as part of colonoscopy. Only the doctor’s fee? That would be shock because there is much more.
William Deffendall
My comment is more about Obamacare than your answer. It is obvious to me that if someone has a pre existing condition they can get “insurance coverage” but it will not cover treatment for preventing your pre existing condition from getting worse. This expense is totally your responsibility until all of your deductible and out-of-pocket is met.What is helpful about this?
ObamaCareFacts.com
We agree, as helpful as the basic free preventive services and the wellness visit are, they only really work on a basic level. The rest of the ten essential benefits are very useful, as they ensure that your essential treatment (including prevention before diagnosis and additional prevention after diagnosis) are covered under the plan’s cost sharing. That is a bonus because it protects people from paying more than their maximum in a policy period.
Phil
The benefit is in your monthly premiums. If you had preexisting condition in the old days you paid a lot more monthly. The costs of treating the issue haven’t changed substantially in terms of doctor costs, deductibles, etc….though you can choose a high deductible to get your monthly premiums even lower.
ObamaCareFacts.com
The lack of clarity is not intentional on our part, rather we simply don’t have the data. It is actually unclear to us exactly how a doctor or insurer will treat an additional procedure related to a specific preventive service. Does this clarify at all?
This is Preventive Care: Preventive care focuses on evaluating your current health status when you are symptom free. Preventive care allows you to obtain early diagnosis and treatment, to help avoid more serious health problems. Through a preventive exam and routine health screenings, your doctor can determine your current health status and detect early warning signs of more serious problems. Your preventive care services may include immunizations, physical exams, lab work and x-rays. During your preventive visit your doctor will determine what tests or health screenings are right for you based on many factors such as your age, gender, overall health status, personal health history and your current health condition.
This isn’t Preventive Care: Medical treatment for specific health conditions, on-going care, lab or other tests necessary to manage or treat a medical issue or health condition are considered diagnostic care or treatment, not preventive care.
TIP: In order to get your free annual wellness visit, you have to make sure your doctor codes it correctly. You can generally ask your doctor and insurer what each service will be coded as. This allows you to find out if a service will be billed as preventive care or not.
Nun Ya
“The lack of clarity is not intentional on our part, rather we simply don’t have the data. “‘
Oh, I forgot, we need to pass the law so we can see what is in it. THE REASON you don’t have the data is because you weren’t interested in the data, you were only interested in cramming another government program down the throats of the unsuspecting public. Just ask Jonathan Gruber. This “LAW” is a joke and a farce on the American public. Our elected representatives should be ashamed for passing this ridiculous law.
ObamaCareFacts.com
We are a private informational site = why we don’t have the data.
I wish I knew Gruber, he was a really smart amazing guy who was crucified in front of the national media in a game of politics. It was actually pretty inhumane if you ask me.
And i’m pretty sure our representatives are proud for COVERING PEOPLE WITH PREEXISTING CONDITIONS and such.
Anonymous
It is impossible to obtain early diagnosis without drawing blood, and testing urine. I am 50 and just had an annual physical and can not believe the entire visit is NOT covered. I pay $15,000 a year in premiums to cover my family with a $6,000/pp deductible. Yet the benefits since Obama took over are half. Disgusting.
H Rajan
The question reads, “What Exactly is covered……”; the answer is not exact, the details are missing, perhaps purposely.
So the lack of clarity (seems purposely created), the insurance companies and/or the doctors take advantage of. In the old days, preventive care included labs and minor/common prescriptions for e.g. thyroid medication or some lipid medication that applies to majority of population.
I had to pay a full doctors visit as a follow up visit after the labs for one prescription (that i’ve been taking for years) – spent 15 minutes at my out of pocket cost of $150. I did not pay for this before – was always included in the preventive care.
Sue e.
Rajan, I could not agree with you more. Lack of clarity in the healthcare law is an invitation to insurers to decline to pay. As port of my annual physical, my doctor took my blood sample and ordered a test under CPT code 82306, among others. My insurer paid the lab for the other CPT tests, but not for the one above. When I asked the insurer to send me the list of all CPT codes covered as part of annual physical, the answer was We cannot share this information with you (!!). So they can kept it secret, but I’m the one getting billed after the fact.
ObamaCareFacts.com
Remember to appeal anything that you disagree with in regards to insurance. You have the right to question every bill on the doctor and insurer end.
Catfish Crawford
This is not because of the insurance company taking advantage of you, this is because of how the laws state “Preventative Care” under the ACA, notice that before the ACA, you said you didnt pay these charges, ask yourself who paid them…ahhhh haaaaa thats right the insurance companies did, now under the “OBAMA Care” or should I state more correctly “the Obama Care has made Health Care a Joke” system, the insurance companies no longer have to pay for those charges…..read the rest of of the facts, its all drawn out. What you had done was not considered Preventative Care Screening for them to do blood work on your existing condition in which you have been taking medication for, for the past several years….now Preventative Care Screenings is only to detect new conditions. If you have a current condition that you have been being treated for in the past now you are having to pay for this as diagnostic screenings. Obama Screwed the Health Care Industry. Study up fool read up on your facts, you probably voted for him twice.
ObamaCareFacts.com
I don’t know that we can blame Obama for the poor wording that lets insurers interpret the clause in an exclusionary way. That is like blaming them for the Medicaid, tax credit, cost sharing, mandate, etc lines that the right-wing libertarian lawyers keep exploiting.
Although to be fair, next time legislation is drafted, it would be smart to make provisions like that a little more iron clad.
J
Don’t fool yourself. It’s still the insurance companies using loopholes to keep from paying for our healthcare. They were refusing healthcare for the sick and raising premiums constantly long before obamacare was even created. Crooked expensive insurance came 1st not Obamacare.
ObamaCareFacts.com
There is truth in this for sure, but by being smart about your plan and knowing what it covers you can get the most bang for your buck. Always question the insurer when you feel a service should have been covered per the terms of your contract. As long as we have billing departments and a for-profit structure we will get rationed service and rejected claims. This is a symptom of the structure of the system, i’m not sure it can be solved with a law, but at least some consumer protections are much better these days and the right to appeal is strengthened.
Tom Turlow
You can hate on Obama all you want but the reality is we let big companies, including health care companies, write the legislation. If you think Obama himself really wanted to make sure your doctor visit and related charges were obscured so the insurance company, and perhaps your doctor, could take advantage, you must not understand how bills are written. We have a thing called congress, controlled by republicans, who are bought off by insurance and other big companies, to do their bidding. Obama’s desire to help all Americans get coverage and not be discriminated against fro pre-existing conditions, was trashed by the congress and companies who fund them. That’s the way it works, and the sooner you realize republicans are not working for you (unless you’re a fortune 500 company or Wall St. exec) the sooner we can get this country off a wicked path of self-destruction.
If progressive democrats were in control of all three branches we would have single-payer insurance like EVERY OTHER CIVILIZED COUNTRY IN THE WORLD! If you want to stop b***ing about the broken system that screws individuals you should have voted for Bernie, or other candidates to the left of Obama. If you keep putting republicans in office you will keep watching the middle class disappear and big companies become more profitable. End of story. Trump has an administration now filled with Wall Street titans and Republican insiders…no draining the swamp, just more of the same, only this time much worse. If you’re one of those out-of-work, uneducated, angry white people, you’re in for a very rude awakening as things go from lousy to horrible. Trust me, Trump is out to hurt you, the individual, hard-working American, not help you.
Erin
Just a note, most of the civilized world has universal healthcare, they are not necessarily all single payer. In fact, only half of the countries on this list of Countries with Universal Coverage is single-payer. Many countries have blended public and private healthcare models, some are private insurance companies paid for with tax funded vouchers for premiums. Some countries like Austria have take completely unique approach to a bunch of social safety net issues by combining public health insurance administration for workers with retirement and unemployment. Many argue that single-payer is the best option, but it is definitely not the only way to achieve cost-effective and universal coverage.
Brian Mallo
Exactly right
Casey
Obamacare (aka ACA; “affordable” being the phony govt. spin word which is supposed to make the sheeple feel all warm and fuzzy about it) was passed WITHOUT ANY republican votes. Compromise was off the table. How’d that work out? OK for a very small minority. Not so good for the rest paying for the Ponzi-like pay system. That said, the problem is NOT with the president, past or present. They both (even Trump) mean well. The problem is with the vast majority of 535 power hungry lifers and wanna be lifers on Capitol Hill who go to work with “for sale” signs on their backs every day. As long as that time honored tradition of “lobbying” (aka, UNETHICAL BRIBERY) is allowed to continue to sour govt., we’ll get more of the same. And to say one party or the other would do the right thing by the people, you have to be living in a make-believe partisan la-la land.
tee smith
Okay Erin, Obama, a democrats in cahoots with a man who constructed obamacare laughed at Americans on how stupid we were for believing in his healthplan. There wasn’t a republican to blame. Face it, look at the facts. Your an idiot. America is laughing at you now!
ObamaCareFacts.com
Actually, that isn’t fully true. Consider:
https://obamacarefacts.com/2017/05/30/the-ongoing-republican-strategy-to-break-obamacare/
https://www.nytimes.com/2017/05/25/opinion/republicans-obamacare-aca.html
lucy
Delusional.
Chris
Let’s start with the term, it’s Preventive not Preventative. In the “Old Days” my insurance company said when they pay out $500,000.00 on my behalf I exhausted my benefit. One Chemo treatment could cost $50,000.00. So anyone who needs more than 10 treatments will die. So much for the good old days oh and if you change jobs and have high blood pressure that’s a preexisting conditions which was not covered for 6 months and you still need to pay your premium.
ObamaCareFacts.com
If you click on the links on this page you can learn more about each service:
obamacarefacts.com/obamacare-preventive-care/
However, in regards to your question. The basic test is covered with no cost sharing, additional services needed for the test are found on the benefits sheet of your specific plan.
Amy
I’d like more detail. Exactly which blood tests are covered? A fasting blood sugar is covered only if you have high hypertension? What if you have a strong family history of diabetes? Or a kidney test (creatinine) for people with a family history of kidney failure? How about bone density testing for post menopausal women. Need more details. Where would I find them?
Gary Goodman
I think MORE should be covered but the answer is clear enough.