How to avoid surprise costs for preventive health services

Avoid surprise costs for preventive care Tuesday, February 19, 2019

Preventive care is key to avoiding conditions or catching them early. On most health plans, you don’t have to pay out-of-pocket for many preventive services. That’s true even if you haven't met your deductible. 

But a trip to the doctor for preventive care sometimes comes with surprise costs.

To help you avoid those unpleasant surprises, we'll explain how to find out what services are included. And we'll tell you what your doctor might recommend that's not considered preventive care.

What's included when it comes to preventive services?

The Affordable Care Act (ACA) lists services that your health plan will pay for in full. Your list might vary if you have your health plan through an employer. The ACA includes a list for adults, additional services for women, and a list for children. 

Examples of adult preventive care benefits include:

  • Blood pressure screening
  • Colon cancer screening, if you're 50-75 years old
  • Type 2 diabetes screening, if you're 40-70 years old and overweight or obese. If you have diabetes, blood and urine tests associated with diabetes are not considered preventive.
  • Immunizations
  • Sexually transmitted infection (STI) counseling and some testing based on gender, age, and risk factors
  • Human immunodeficiency virus (HIV) screening

Preventive care benefits for women include but aren't limited to:

  • Anemia screening
  • Breastfeeding support and counseling for women who are pregnant or nursing
  • Birth control and contraceptive care

Examples of preventive care benefits for children:

  • Newborn metabolic screening
  • Behavioral assessments
  • Blood pressure screening
  • Height, weight, and body mass index (BMI) measurements
  • Immunizations
  • Hearing and vision screening

What preventive services aren't included?

Your doctor might recommend services that you might need but aren't on the preventive lists or they may perform these services at your preventive visit, without alerting you that you might pay more.

Discussion about other issues that are not preventive (such as asking about a hurt knee or blood pressure management), may result in an additional charge for an office visit.
Some preventive services might come with surprise costs:

  • Preventive services might not be covered if you don’t have risk factors or if your doctor does them more often than is recommended.
  • Blood tests called a "general health panel." This is a set of tests that includes your blood count and levels of calcium, potassium, thyroid stimulating hormone, bilirubin and others in your blood.
  • Vitamin D deficiency screening. Doctors may recommend a vitamin D supplement if it could benefit you, even without this test. Ask your doctor if the test results will change the treatment plan.
  • Comprehensive adult eye exam (unless you have vision coverage). A simple vision screening is not typically billed separately from a preventive exam.

How can you avoid surprise costs before you get a bill?

  1. Make sure your doctor is in your health plan's network. Use the Find a Doctor tool or ask when you make an appointment. Make sure to give the name of your plan's specific network (on your ID card) because Premera offers different plans with different networks.
  2. Be clear when you schedule a doctor visit. Let them know you're only interested in preventive services.
  3. Don't be afraid to ask questions about costs. Do I really need this test? What are the risks? What if I don't do anything? About how much will it cost?
  4. Some preventive services may only be covered 100 percent if they happen during your annual preventive checkup. So print this list from and use it to make sure you don't miss anything.
  5. Make sure your doctor uses a lab that is in your health plan's network. Sometimes your doctor sends tests or sends you to an out-of-network lab. You can always pull up your Premera app at your appointment and find an in-network lab. Also ask if your doctor is ordering lab panels (several tests in a set). Sometimes not all the tests are covered. You can confirm with your doctor using the preventive care list. Read more about avoiding surprise lab costs.

Popular Articles