#ACA / ObamaCare Preventative Care & Wellness Programs

Anthem Preventative Care

• Here’s a Plain English List!  from HealthCare.Gov  of preventative services you can get with NO DEDUCTIBLE.
  • For all adults
  • For women
  • For children
• However, if Preventive care is given during an Office Visit or as an outpatient or vice versa ^{Covered CA}  it might not be covered under the Preventative Care section of your policy   Check with your doctor. Preventative Screenings and other services are covered with no deductible for adults and children with no current symptoms or history of a health problem. ^{Specimen Policy Page 92} 
  • If one has history or symptoms, then it’s covered under the diagnostic benefit ^{Page 74}  Subject to Co-Pays & the Deductible.   Maintenance of a known problem, like those listed below as common risk factors,  is certainly preventative, but isn’t defined that way under ObamaCare and is subject to the regular co-pays and deductibles.  Peter Lee of Covered CA thinks that’s a BIG problem, read more by on the link.  Annual physicals may not be a benefit ^{LA Times 8.2.2016}
    • Ouch. That ‘Free’ Annual Checkup Might Cost You. Here’s Why 
    • Preventive care doctor visits are free, but if you bring up a health concern during the appointment, the visit may turn into a traditional doctor visit. That means you would have to pay a copay. The same could go for any tests that lead to more treatment or follow-up visits.  Learn More Covered CA  *
• Health Care Reform hopes to save premium dollars as 20% of Employee Health Care Spending is on these common risk factors: ^{health net pulse.com/}
  • stress
  • depression
  • high blood pressure
  • high cholesterol
    • What It Means if You Have Borderline High Cholesterol—And What to Do About It
  • obesity
    • poor diet
    • physical inactivity
    • high blood glucose
  • excessive alcohol use
  • tobacco use
    • CDC on How to Quit Smoking
  • US Preventative Services Task Force – Consumer Information for tons of different problems

Resources & Links

• A federal appeals court in Texas  on 6.21.2024 (read courts actual ruling)  found unconstitutional a key component of the Affordable Care Act that grants a health task force the effective authority to require that insurers both cover an array of preventive health interventions and screenings and refrain from imposing out-of-pocket costs for them. ^{NBC News} *
  • Appeals Court Hears Appeal Over Obamacare’s Preventive Care Mandate KFF 3.5.2024
  • The Texas ruling of March 30, 2023 (KFF Summary) * KFF update 4.7.2023 *  doesn’t count in CA.  Please don’t take blanket summaries & hype as gospel.  Read the sources links
• California law that requires all health plans regulated by the State of California to cover the same necessary preventive services at no cost to the patient, consumers enrolled in plans offered through Covered California will continue to have access to these critical health care services without disruption.  ^{Covered CA Email dated 4.6.2023 * Joint Statement *} 
• FAQ finding doctors, labs and hospitals, when there’s confusion

#Mammogram coverage under Medicare

Breast cancer screening (mammograms)

Breast cancer is the most common non-skin cancer in women and the second leading cause of cancer death in women in the U. S. Every woman is at risk, and this risk increases with age. Breast cancer usually can be treated successfully when found early. Medicare covers screening mammograms and digital technologies to check for breast cancer before you or a doctor may be able to find it manually.

Who’s covered?

Women 40 and older are eligible for a screening mammogram every 12 months. Medicare also covers one baseline mammogram for women between 35–39.

How often is it covered?

Once every 12 months.

Your costs if you have Original Medicare

You pay nothing for the test if the doctor accepts assignment.

Am I at high risk for breast cancer?

Your risk of developing breast cancer increases if any of these are true:

• You had breast cancer in the past.

• You have a family history of breast cancer (like a mother, sister, daughter, or 2 or more close relatives who’ve had breast cancer).

• You had your first baby after age 30.

• You’ve never had a baby.

Other pages on our website dealing with cancer and how Insurance and Rx Prescription coverage might pay for it

How often are Eye exams covered?

Medicare doesn’t cover routine eye exams (sometimes called “eye refractions”) for eyeglasses or contact lenses. Medicare Part B (Medical Insurance) covers some preventive and diagnostic eye exams:

• Yearly eye exam
• Glaucoma tests
• Macular degeneration
• Medicare Part B (Medical Insurance) covers a yearly eye exam for diabetic retinopathy
  • ICD 10
  • Web MD

by an eye doctor who’s legally allowed to do the test in your state.

Who’s eligible?

All people with Part B who have diabetes are covered.

Your costs in Original Medicare

You pay 20% of the Medicare-approved amount for the doctor’s services, and the Part B deductible applies. In a hospital outpatient setting, you pay a copayment.

Note

To find out how much your specific test, item, or service will cost, talk to your doctor or other health care provider. The specific amount you’ll owe may depend on several things, like other insurance you may have, how much your doctor charges, whether your doctor accepts assignment, the type of facility, and the location where you get your test, item, or service. ^{medicare.gov yearly-eye-exam}

• cms.gov/VisionServices_FactSheet
• FAQs / Ask Us a Question
• ICD billing codes
  • 92012 Ophthalmological services: medical examination and evaluation, with initiation or continuation of diagnostic and treatment program; intermediate, established patient
  • 92083 — extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus programs G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).
  • 92083 — extended examination (eg, Goldmann visual fields with at least 3 isopters plotted and static determination within the central 30 degrees, or quantitative, automated threshold perimetry, Octopus programs G-1, 32 or 42, Humphrey visual field analyzer full threshold programs 30-2, 24-2, or 30/60-2).

Child & Related Pages – Site Map 

Medi-Cal Share of Cost

If you are low income you might check out LIS – Low Income Subsidy – Extra Help to pay the Rx costs that are not covered.  LIS may also pay your Part D and Part B premiums and you might also qualify for Medi-Cal.

Part D Rx Low Income Subsidy – LIS – Extra Help

• More help – beyond LIS
  • Rx Assistance from Manufacturer
  • Rx Covered Under Part B