Martine G. Brousse helps people wade through confusing medical bills. She says many ask why they were billed by their doctors for what they thought was a free preventive service.
"It happens more often than you think," says Brousse, a Santa Monica patient advocate and medical billing specialist. She runs a firm called AdviMed.
The Affordable Care Act requires most insurers to cover the full cost of preventive care, such as check-ups, vaccinations and screenings. But when it comes to determining whether services are considered preventive — or are treatments that require payment — the details can get fuzzy. And many people still aren't aware of the benefits available to them.
A survey by the Kaiser Family Foundation last year found that fewer than half of the population said they understood that the law eliminated out-of-pocket expenses for preventive services. Among young people who may be insured for the first time, awareness is even lower.
"We know young people compared to older adults have less health insurance literacy overall," says Christina Postolowski, health policy manager with Young Invincibles, a national organization that seeks to represent the interests of 18- to 34-year-olds.
Experts outline the guidelines that dictate whether you can expect your visit to the doctor to be free of charge — and what to do if you believe you've been incorrectly billed.
Know the law: Under the law, vaccinations, cancer and other health screenings, annual wellness visits, breast pumps and FDA-approved contraceptives are free in most cases.
These requirements apply to all private plans with the exception of those that are grandfathered — health plans that were in place when the law took effect March 23, 2010.
Understand the guidelines: The guidelines that determine which medical services are preventive are set by medical and scientific authorities. Whether insurance will cover your visit in full is contained in details of the specific recommendations.
For a complete list of preventive health services available cost-free, see the Kaiser Family Foundation's Prevention Services Tracker: kff.org/health-reform/report/preventive-services-tracker.
For example, the guidelines state that mammograms are recommended every one to two years for women 40 and older. "If you have no risk for breast cancer and want a mammogram at age 35, your insurer is under no obligation to cover that," says Alina Salganicoff, vice president and director of women's health policy with the Kaiser Family Foundation.
Know your insurer's specific rules. It's also important to confirm how your insurer interprets the guidelines.
For example, insurers are required to cover all 18 methods of FDA-approved contraceptives, but they don't have to cover the particular brand you prefer. Instead, your insurer may pay only for the generic alternative.
Stay in your health plan's provider network. For preventive services to be cost-free they must be delivered by a doctor in your health plan. If you see a doctor outside your plan's network, you can expect to be charged.
Is the visit preventive? If in the middle of a preventive exam you discuss your diabetes or your doctor makes an adjustment to your medication, the office visit and the preventive service may be billed separately. In that case, the preventive service must be without cost, but your insurer may still require you to pay your part for the office visit.
That's because "the scope of what the provider offered goes beyond a preventive visit," says Dr. Claire Brindis, professor of pediatrics and health policy at UC San Francisco. "Find out how that visit will be billed if it has additional service components," she says.
Mention prevention upfront. Be clear about why you're going to see your doctor when you make your appointment.
"To set up a well-women visit that's free, you might need to say on the phone when you're making your appointment, 'I want my free well-women visit,'" Postolowski says. "Not everyone knows to do that, so they may be charged a co-pay later because the office thought it was just a general appointment."
Question unexpected bills. If you get a bill you think is in error, question it.
Call your doctor's office to clarify exactly what transpired during your visit. Sometimes it's a simple billing error that can be easily fixed with a call.
Your health plan may also be able to step in on your behalf to get a payment issue resolved.
If coverage is denied, you can also file an appeal with your health plan.
Brousse says that in addition to confusion over billing, she talks to many people who still don't know that preventive services are available at no cost. "We need to do a better job educating people."
Resources and links
A complete list of preventive health services that should be available cost-free: www.healthcare.gov/what-are-my-preventive-care-benefits and Kaiser Family Foundation's Prevention Services Tracker.
HMO appeals: California Department of Managed Care at (888) 466-2219 or healthhelp.ca.gov.
Insurance appeals: California Department of Insurance at (800) 927-HELP (4357) or insurance.ca.gov