When Is Preventive Care Free And When Do You Pay?

The still-relatively new federal health care law makes dozens of preventive tests free for patients. Doctors or hospitals are not supposed to charge patients for annual check-ups, most screening tests and a dozen other services such as tobacco cessation. This provision began taking effect more than a year ago, but there is still confusion about how it works.

Arelis Gomes, an outreach coordinator at Health Care for All, spends her days deciphering and explaining the Affordable Care Act, or ACA. For more than a year now she’s been telling consumers that they will no longer have to pay anything for preventive care.

So, when Gomes arrived at her doctor's office a few weeks ago for her annual check-up, she was surprised when the receptionist asked her for a co-pay.

"And I said, 'Actually I know for a fact that under the ACA we do not have to pay a co-pay for this visit because it’s a preventative visit,' " Gomes remembers telling the receptionist. "And she said 'No, I’m not aware of that and we’re not allowed to take you in today for this visit if you don’t pay the co-pay.' "

After a frustrating back and forth, with her husband looking on, Gomes paid the co-pay.

Gomes appealed the payment with her insurer and expects to receive a rebate. As Gomes shares her story to friends and audiences, she says many people don’t know they are not supposed to be charged for preventive care.

Among people who do know, there is still confusion about what is free and what is not. If you go in for an annual check-up the visit won’t cost you anything but you will still have a charge for the lab work your doctor orders. And some tests may start off as a preventive screening, but then switch to a diagnostic test if a doctors finds a problem.

Take, for example, a colonoscopy. It will not cost you anything unless the doctor finds a polyp, which happens fairly often. If the doctor does find a polyp while you are lying there on the table, the test is no longer a preventive screening, it’s a procedure and there will be a charge.

Jill Madigan, a self-employed 57-year-old, found this out during a call to her insurer.

"I said, 'If they bill it as routine and they find polyps, are you going to say it’s not routine?' " Madigan asked the insurance representative. "And she said yes."

Some patients would just get a bill for the co-payment. But if Madigan’s preventive colonoscopy becomes a surgical procedure to remove polyps, she’d be expected to pay the full charge — about $1,500, because she has a deductible.

So is she thinking about skipping the test?

"Well, yeah, I’ve been thinking about it," Madigan said. "The likelihood is that I probably will have the test. I’m not sure I’m willing to take that risk with my life and yet, the whole system is messed up."

Messed up, Madigan says, because if she declined the test but eventually needed colon surgery, it would cost much more than a colonoscopy.

Now, to be clear, before the health care law was passed, Madigan would have had to pay for the test whether it was preventive or not. But she and other patients are upset by what now feels like a bait and switch.

The option of free, preventive care is coming at a time when more and more patients have deductibles or rising co-payments.

Dr. Tom Hines, president of the Massachusetts Academy of Family Physicians, mentions the example of a woman coming in for a pap smear. If that test shows something abnormal it triggers the need for a more specialized test.

"It’s not an uncommon situation for a patient to delay that follow-up appointment," Hines said. "If you unearth something, it’s important to follow up on the problem that’s been unearthed."

Supporters of the law say it’s important not to overlook the benefits of encouraging patients to get preventive care. Employers and insurers still pay for the visits and tests, they just don’t pass along any costs to the patient.

"It is a clear advantage for the employee or retiree as the case may be," said Dolores Mitchell said, who runs the Massachusetts Group Insurance Commission, which covers more than 350,000 retirees, employees and their families. She says the lesson, while there is still confusion about this part of the law, is to ask a lot of questions about what your doctor is prescribing and why.

"It’s a good thing to be a pushy patient who asks questions," Mitchell said. "There are an awful lot of procedures out there that are subject to some difference of opinion about what’s preventive. It will take some shakedown time before it all gets resolved."

In the meantime, your insurance company should have a list of procedures considered preventive, for which you won’t be charged. Here are the lists for some of the states largest insurers:

This story is part of a reporting partnership that includes WBUR, NPR and Kaiser Health News.