ACA Preventive Care: Understanding What’s Covered and What’s Not

Under the Affordable Care Act (ACA), health insurance plans are required to cover a range of preventive services without any cost-sharing, such as deductibles or copayments. However, not all services that may be recommended or performed during a routine checkup are considered preventive care under the ACA guidelines.

CPT Code 80048: Basic Metabolic Panel Calcium Total

This test measures the levels of various substances in the blood, including glucose, calcium, electrolytes, and kidney function. While it is often ordered as part of a preventive checkup, it is not specifically required under the ACA preventive care guidelines. As a result, insurance companies may not cover this test without cost-sharing.

CPT Code 85027: Complete CBC

This test provides information about the types and counts of cells in the blood, including red blood cells, white blood cells, and platelets. Again, while it is often included in a routine checkup, it is not considered a required preventive service under the ACA. Therefore, insurance companies may also not cover this test without cost-sharing.

When Preventive Care Services Are Not Covered

There are several reasons why preventive care services may not be covered by insurance, even if they are ordered or performed during a routine checkup. These reasons include:

Age or Gender: Some preventive care services are only covered for certain age groups or genders.
Medical Necessity: The service must be considered medically necessary to be covered as preventive care.
Billing Codes: The service must be billed using the correct billing codes to be covered under the ACA preventive care guidelines.
Overuse: Some services, such as blood tests, may only be covered once or twice per year.

Seeking Clarification from Your Insurance Provider

If you receive a bill for a preventive care service that you believe should be covered without cost-sharing, it is important to contact your insurance provider to seek clarification. They can review the billing codes and medical documentation to determine whether the service should be covered under the ACA guidelines.

Tips for Understanding Your Preventive Care Coverage

Review your insurance plan documents: These documents will provide details about the preventive care services that are covered.
Ask your doctor: Your doctor can help you understand which services are considered preventive care under the ACA.
Use a reputable source: There are many reputable websites and resources that can provide information about ACA preventive care coverage.
Contact a licensed insurance agent: A licensed insurance agent can help you understand your coverage options and ensure that you are enrolled in a plan that meets your needs.

Remember, seeking clarification from your insurance provider or a licensed insurance agent is crucial to ensure that you are receiving the appropriate coverage and avoiding unnecessary out-of-pocket expenses.