Understanding Obamacare's Preventive Health Care Benefits
Get a colonoscopy, mammogram, vaccinations, and other essential services for free
The Affordable Care Act requires health insurance plans to offer certain preventive care services free of charge -- or more accurately, for nothing more than the cost of your monthly insurance premiums. This rule applies to most plans sold directly by insurance companies and all plans sold through $EXCHANGE, the health care marketplace for South Dakota. Covered preventive services are available for free (meaning no co-pay or other out-of-pocket charges) whether or not you’ve met your plan’s annual deductible.
Tips for Using Your Preventive Care Benefits – And Avoiding Unexpected Charges
Below, you’ll find a list of free preventive benefits -- screening tests, counseling services, and vaccinations -- for adults, women, and kids. But first, here are some pointers to help you avoid an unexpected bill for services you thought were preventive.
Use a network provider. To get a preventive service for free, you must use a health care provider in your insurance plan’s network.
Know the difference between “preventive” and “diagnostic.” Doctors can use screening tests for either preventive or diagnostic reasons. For example, having a routine mammogram every year or two is preventive care for women over 40. But if you schedule a mammogram because you feel a lump or have breast pain, that’s diagnostic. Likewise, a routine colonoscopy is recommended for adults over 50, but if your doctor schedules a colonoscopy to investigate a problem like blood in your stool, it becomes a diagnostic procedure. Preventative services are free; diagnostic procedures are not. (If the timing is right -- say, you go to the doctor because you find a lump in your breast but you also happen to be due for an annual mammogram -- your doctor may bill the diagnostic procedure as preventive, but that’s not something you can count on.)
Talk to your health care providers and read your billing statements carefully. Some people seeking preventive services from in-plan doctors and hospitals have been dismayed to find themselves facing big bills later. For example, one 53-year-old woman received a preventive colonoscopy, but then got a bill for a hospital facility fee of $1395. Experiences like these aren’t uncommon as doctors and hospitals figure out how to comply with Obamacare’s preventive service requirements.
When you schedule a preventive visit, call ahead to be sure you’re eligible for no-cost care and make it clear you’re not expecting a bill. At the appointment, ask your doctor or other provider to tell you if the visit looks like it’s shifting from preventive care to treatment -- that is, turning into something you could be billed for -- or if the provider is ordering extra tests or procedures that aren't considered preventive.
If you do get a bill, check to make sure you weren’t charged for anything you were told would be preventive. Finally, if you believe you’ve been incorrectly billed for a preventive service, talk to your health care provider and, if necessary, your insurance company.
Do some research. The resources that accompany this article do a great job of explaining the ups and downs of preventive care benefits. We particularly like the FAQs from the Center for Consumer Information and Insurance Oversight at CMS.gov. This in-depth series of questions and answers provides official details that you won't find on HealthCare.gov.
Preventive Health Care Benefits for Adults
- abdominal aortic aneurysm screening for certain men with a history of smoking
- alcohol misuse screening and counseling
- asprin used to prevent cardiovascular disease for older adults
- blood pressure screening
- cholestorol screening for adults of certain ages or at higher risk
- colorectal cancer screening (including colonoscopy) for adults over 50
- depression screening
- diabetes (Type 2) screening for adults with high blood pressure
- diet counseling for adults at higher risk for chronic disease
- hepatitis B screening for adults at high risk
- hepatitis C screening for adults at risk, plus one time for anyone born between 1945-1965
- HIV screening for people ages 15-65, plus others at high risk
- immunization vaccines
- lung cancer screening for high-risk adults aged 55-80
- obesity screening and counseling
- sexually transmitted infection (STI) prevention counseling for high-risk adults
- syphilis screening for high-risk adults
- tobacco-use screening and cessation interventions
Additional Preventive Health Care Benefits for Women
- anemia screening for pregnant women
- asprin therapy for women at risk for preeclampsia
- breast cancer genetic test counseling (BRCA) for women at higher risk for breast cancer
- breast cancer mammography screenings every 1-2 years for women over 40
- breast cancer chemoprevention counseling for women at higher risk
- breastfeeding support and counseling, plus access to breastfeeding supplies
- cervical cancer screening for sexually active women
- chlamydia infection screening for younger women and other women at higher risk
- contraception for FDA approved methods (does not include all brands and does not apply to health plans offered by certain “religious employers”)
- domestic and interpersonal violence screening and counseling
- folic acid supplements for pregnant women
- gestational diabetes screening for women 24-28 weeks pregnant and those at high risk of developing gestational diabetes
- gonorrhea screening for all women at higher risk
- hepatitis B screening for pregnant women at their first prenatal visit
- HIV screening and counseling for sexually active women
- human papillomavirus (HPV) DNA Test every 3 years for women with normal cytology results who are 30 or older
- osteoporosis screening for many women over age 60
- Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Sexually Transmitted Infections counseling for sexually active women
- Syphilis screening for all pregnant women or other women at increased risk
- Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
- Urinary tract or other infection screening for pregnant women
- Well-woman visits to get recommended services for women under 65
Preventive Health Care Benefits for Children
- Alcohol and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments
- Blood pressure screening
- Cervical Dysplasia Screening for sexually active girls
- Depression screening for adolescents
- Developmental screening for children under age 3
- Dyslipidemia screening for children at higher risk of lipid disorders
- Fluoride chemoprevention supplements for children without fluoride in their water source
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns
- Height, Weight and Body Mass Index measurements
- Hematocrit or Hemoglobin screening for children
- Hemoglobinopathies or sickle cell screening for newborns
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- Immunization vaccines
- Iron supplements for children ages 6 to 12 months at risk for anemia
- Lead screening for children at risk of exposure
- Medical history for all children throughout development
- Obesity screening and counseling
- Oral Health risk assessment for young children
- Phenylketonuria (PKU) screening for this genetic disorder in newborns
- Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis
- Vision screening for all children
- Well-baby and well-child visits until a child reaches age 21
Preventive Health Care Benefits for Seniors
The Affordable Care Act strengthened Medicare by adding new preventive services and helping to close the “donut hole” for prescription drug coverage. To learn more about preventive services for seniors, see How the Affordable Care Act Helps Seniors, from the National Committee to Preserve Social Security and Medicare.
To find out how to get covered, see How to Sign Up for Obamacare in South Dakota.
To learn about the costs of marketplace health insurance plans, see How Much Does Obamacare Cost in South Dakota?
For more information on the cost-saving subsidies that may be available for marketplace plans, see Ways to Save Money on Obamacare in South Dakota.
List of preventive services for adults, women, and children adapted from "What are my preventive care benefits?" at HealthCare.gov.