QUESTION

Are annual physicals for adults and children available without cost-sharing as part of the preventive service requirements?

Post enrollment issues | Individual Health Insurance
ANSWER

Yes, routine annual physicals are covered as part of the preventive service requirements of the ACA.

Under federal rules, insurers must provide coverage for preventive health services that the United States Preventive Services Task Force (USPSTF) recommends at an A or B rating without any cost-sharing requirements such as a copayment, coinsurance, or deductible. This means that insurers must provide coverage for preventive health services currently recommended by the USPSTF and federal guidance. You can find a list of USPSTF recommended preventive services here.

For example, if you are man 35 and older and go to the doctor’s office for an annual physical, and are screened for cholesterol abnormalities as part of your annual physical, the insurance company cannot impose cost-sharing for either the physical or the cholesterol abnormalities screening. Note, however, that the law covers preventive care – if there is a medical reason for a service, then you may have some cost-sharing requirements. Take the previous example with the man 35 and older, if he goes into his annual physical to discuss reoccurring stomach pain and the doctor bills separately for an office visit for any services to address the stomach pain, these services will likely not be considered preventive care.

Some plans will also cover some limited services prior to meeting a deductible such as primary care visits, some urgent care, or a limited number of prescription drug refills. Check your Summary of Benefits and Coverage for information on what services are covered before the deductible is met.

Note that not all plans must comply with the ACA’s preventive services requirement. See the alternative coverage section to learn more. (45 CFR § 147.130(a)(2)).

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Post enrollment issues