Take Advantage of Expanded Preventive Health Care Coverage

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Take Advantage of Expanded Preventive Health Care Coverage

The Affordable Care Act cuts out-of-pocket expenses for preventive care like mammograms and cholesterol screenings.

I'm about to make an appointment with my doctor for an annual checkup. I've heard that I no longer have to pay out-of-pocket expenses for preventive care under the new health care law. Can you give details?

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Most health plans must now provide a variety of preventive-care benefits without charging a deductible, fees or co-payments, even if you have not yet met your plan's deductible for the year. Among the benefits that are fully covered: screenings for high blood pressure (all adults), high cholesterol (adults with a history of high cholesterol), colorectal cancer (adults over age 50) and Type 2 diabetes (adults with high blood pressure). Women over 40 can get fully covered mammograms every one or two years, depending on their risk factors. You are also entitled to several immunizations, depending on age, as well as a long list of other tests and services, depending on your age and health. For children, the fully covered benefits include routine vaccinations, well-baby and well-child visits, and other preventive services. See the preventive-care page at Healthcare.gov for a full list of all these preventive services and eligibility requirements.

Expanded coverage doesn't get you off the hook for some expenses. For instance, you may still have to pay for the office visit if the preventive service is not the primary purpose of your visit, or if you use an out-of-network provider. And the law includes one big loophole: It does not require insurers to provide these no-charge benefits if the plan has not made major changes to its costs and benefits since health-care reform was enacted (called a grandfathered plan). Ask your insurer or employer's benefits office if your plan falls under the new law.


Medicare beneficiaries also receive expanded coverage for preventive benefits. You can get a fully covered physical under the "Welcome to Medicare" program if you have the exam within the first year after you sign up for Medicare Part B, and you're entitled to a personalized prevention plan and an annual wellness visit without any cost sharing. Depending on your age, you get 100% coverage for screenings for cervical cancer, colorectal cancer and high cholesterol; flu shots, pneumonia shots and the hepatitis B shot; mammograms for women; and certain kinds of prostate screenings for men. Although the screenings themselves are fully covered, you may still have to pay for the doctor's visit.

The new coverage rules apply to people who are covered by original Medicare; the coverage rules for preventive services may be different if you have a Medicare Advantage plan.

"We've known for a number of years that these tests were important, but many people didn't get them because of time or costs, or because they were afraid," says Jan Berger, chief medical officer for Silverlink Communications, which provides consumer information on Medicare health plans. "These benefits provide short-term value and long-term value."

See the Preventive Services page at Medicare.gov and Your Guide to Medicare's Preventive Services for a full list of covered services. Medicare.gov also has a helpful Preventive Services Checklist that you can take to your doctor so he or she can record the date you received each screening and the date when the next one is due.

Got a question? Ask Kim at askkim@kiplinger.com.