Preventive Care

Preventive care is a defined list of services that ACA-qualified health plans must cover at 100 percent, with no deductible, copay, or coinsurance, when delivered in-network. The list is set by the US Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP), and HRSA guidelines for women's and children's health. It includes annual physicals, most vaccines, colorectal cancer screening starting at age 45, mammograms, cervical cancer screening, blood pressure and diabetes screening, and many others.

The trap is how the visit gets coded. A screening colonoscopy for a person with no symptoms (ICD-10 Z12.11) is preventive and covered at 100 percent. The same procedure coded as diagnostic (say K92.1 for rectal bleeding) applies the plan's deductible and coinsurance — same colonoscopy, same facility, dramatically different bill. Polyp removal during a screening colonoscopy used to trigger a switch to diagnostic coding, but ACA guidance now clarifies it stays preventive. Wellness visits that drift into addressing an active complaint can also trigger a diagnostic billing code, generating a surprise cost-share on what the member thought was a "free" annual physical.

The takeaway: before any preventive visit or screening, confirm with the provider's office that it will be billed as preventive under your plan. If you get a bill after what should have been a preventive service, dispute the coding first — the fix is often a code change, not a payment.