25 Jun Helping You Navigate Preventive Care

There’s nothing more important to us than keeping your family healthy and happy. That’s why we go above and beyond to help our members understand how to make the most of their preventive care benefits without the surprise of unexpected charges.

It’s more complicated than it should be. The law requires every insurance company to provide certain preventive care benefits at no cost to enrollees. An annual wellness exam is one example of a no-cost preventive healthcare service, but there are others that are narrowly defined by law, and are sometimes customized to your age, gender, and medical history.

Policymakers decided to include in the definition of no-cost preventive care only services that have been proven highly effective and worth the price. That’s because the cost of these services are built into monthly insurance premiums, and they were concerned that a broader definition make the cost of health insurance unaffordable for many Americans.

This is where members have run into trouble. In the last ten years of fighting to make healthcare better for our members, we’ve seen a handful of issues rise to the top of concerns about preventive care. We have shared these with our provider partners, and we thought it would be helpful to share these with you:

• • • A doctor recommends a test or service that falls outside the definition. Doctors might think that ordering additional tests or screenings won’t hurt patients, but we understand that unexpected charges are painful. You can find out more about the list of no-cost preventive services here.
    • Care is meant to diagnose a problem and therefore is not preventive. Doctors will bill your care as diagnostic if they are ordering tests in response to a concern you have raised about your health. This is true even if you raise the concern during a preventive care visit. In these situations, it’s possible that neither the test nor the visit will be considered preventive under the law or by your doctor.
    • Care is out-of-network. Only in-network providers can deliver no-cost preventive care. To make sure your provider is in-network, please call us before your visit.
    • A colonoscopy is recommended more often due to a history of polyps or precancerous cells. Colonoscopies should be billed by doctors as preventive when there is zero concern for your health prior to the colonoscopy. But if something of concern was found in a prior colonoscopy, your doctor will recommend you get colonoscopies more often and they will not be covered as no-cost preventive care. The same would be true for mammograms or blood tests ordered for diagnostic reasons.

Have concerns? Here are some ideas to address them. If you read this before your annual wellness exam, please have a conversation with your doctor at the outset of your visit about no-cost preventive care. Let them know you want to be made aware of anything done during the exam that would fall outside of the federal recommendations for preventive care. It is your right to make decisions together with your doctor about the medical care you receive.

If you’ve already had your visit and you think you may have been billed incorrectly, please call our member services department. We are on your side and will do everything we can to help if you’ve been billed incorrectly. We’ve helped countless members work through concerns with their medical bills over the years.

If you think the law should be different when it comes to preventive care, please make your voice heard! The federal government has the authority to expand the definition of no-cost preventive care for everyone. Just visit USA.gov/elected-officials to find the contact information for who represents you in Congress. You can call their offices or fill out a contact form on their websites. CGHC and other consumer advocacy organizations have been successful in getting consumer pain points addressed through advocacy efforts like these.

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