ObamaMESS: What qualifies as Preventive Care and will it cost me?

Access to preventive care at no charge to the patient is a key tenet of the federal health law. But questions about what qualifies as "preventive" are causing discord between doctors and patients, particularly when it comes to the traditional annual checkup. 

Some patients, anticipating free visits to address all their health issues—past, present and potential—are upset to find that only some of that qualifies as preventive care, exempt from deductibles and copays.

"Patients are scheduling 'physicals' because physicals are free," says Randy Wexler, a family-medicine physician in Columbus, Ohio. "But they come in and say, 'I've been having headaches. My back has been bothering me and I'm depressed.' That's not part of a physical. That will trigger a copay." 

A long list of services do qualify as preventive care under the Affordable Care Act, including vaccinations and screenings for diabetes, depression, high blood pressure, high cholesterol and several cancers. Most insurers will cover one such preventive visit per year with no charge to the patient.

But care related to existing health problems, or new issues, is considered "evaluation and monitoring," not preventive. 

That is hard for some patients to grasp, doctors report. "They'll say, 'I have diabetes and hypertension and heart disease and seeing you is preventing them from getting worse, so that should be fully covered,' " Dr. Wexler says. "But under that theory, everything would be free with no copay."

Some offices now ask patients to schedule separate annual visits—one for preventive care (with no out-of-pocket cost) and one to discuss problems (with the usual deductible and copay). Medicare also encourages preventive care with its annual free "wellness" visits. But when elderly patients learn they can't bring up ongoing health issues at such a visit without being charged, many don't bother, doctors say. 

Some insurers let doctors bill for preventive and nonpreventive services in the same visit using a special code ("modifier 25"). But that does trigger patient copay—and sometimes patient ire.

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