What and how much is covered for Lab – Laboratory Fees – as an essential benefit  under Health Care Reform?

Is the $10 limit for most X-rays and laboratory test limited only to this Blue Shield Platinum plan? 

***I believe the co-pay would depend on what Metal Level, one has purchased.

Are the words “most” and “encounter” defined anywhere? 

***Proactive Office Encounter is a Kaiser Term – Here’s an explanation… but I don’t find a simple definition. 

I see that essential benefits include laboratory tests for PSA, cholesterol and diabetes are no charge items as they are deemed preventative care

***Yes, but see the limitation for conditions that are already diagnosed!

Our current Blue Shield of CA PPO small business plan took effect on July 1, 2011.  As I have previously explained, when I last had routine lab tests, which was in October, 2012, the cost was over $1,000 from an in-network provider.  So, since the Affordable Care Act has taken more full effect, is there any chance those lab tests which are now deemed preventative care and thus no charge,

***I’m glad you’ve asked this question… I don’t think ANYONE knows of the limitation for what’s already been diagnosed.

will be no charge under our current plan, or will we have to wait until a new plan is in effect?

Lab Fees are an essential benefit.   


Preventive Care

Preventive care is given during an Office Visit or as an outpatient. Screenings and other services are covered for adults and children with no current symptoms or history of a health problem. Members who have current symptoms or a diagnosed health problem will get benefits under the “Diagnostic Services” (Page 74) benefit, not this benefit. – Page 92


Office Visits

An Office Visit is when You go to a Physician’s office and have one or more of ONLY the following three services provided: 

  • History-Gathering of information on an illness or injury. 
  • Examination 
  • Physician’s medical decision regarding the diagnosis and treatment plan.

Office Visit will not include any other services while at the office of a Physician (e.g., any surgery, Infusion Therapy, diagnostic X-ray, laboratory, pathology and radiology) or any services performed other than the three services specifically listed above.

Covered Services include: 

Office Visits with Primary care Physicians and Providers (PCP) and Specialty Care Physicians and Providers 

Home Visits for medical care to examine, diagnose, and treat an illness or injury.

Note:  Physician visits in the home are different than the “Home Care Services” benefit described earlier in this Agreement (Page 88)

Sample Evidence of Coverage EOC Platinum Level 

USC  United States Code on  Essential Benefits  

149 page final.rule_.essential.health.benefits




  detail.per.encounterbenchmark.Kaiser Small Group HMO


One might also consider these options for fees that don’t get paid


Section 105  medical_expense_reimbursement_plans_section_105.


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