Preventive Care Billing Explained
ALL PLANS fully cover ONE preventive office visit per year, usually called a “well visit” or “annual physical.”
“Sick appointments,” or doctor visits you request because of illness or other health concerns, will carry a cost depending on the specifics of your plan.
Sometimes the preventive service is free, but the doctor visit isn’t. For example: you go to the doctor for a checkup because you feel ill or are experiencing pain. At the appointment, the doctor notices you haven’t received your annual flu shot. So, you opt to also receive the flu shot at your appointment.
Do you have to pay? Yes - but NOT for the flu shot. In this case, the flu shot is free, but you will still have to pay for the office visit because it was not preventive.
Sometimes preventive services are free the first time you receive them in a plan year. If you need the same service more than once within your plan year, that service will cost money. For example: Say you receive a routine colonoscopy, and based on the results, your doctor wants you to have a follow-up colonoscopy six months later.
Do you have to pay? If you have Essential Plan 2, 3, or 4, no. If you have Essential Plan 1, yes. The first colonoscopy will be free because it is considered a preventive screening. The second colonoscopy is a follow-up and thus NOT preventive, and you will need to pay for it according to the specifics of your plan.
Prescription drugs are covered differently depending on the type of coverage you carry. Please refer to your plan’s specific drug coverage information for guidance.