Theme music up and under: Something symphonic with a sort-of Masterpiece Theater feel.

V/O: Welcome to Health Care Reform Demystified. Today’s episode: Preventive Care Coverage under the Affordable Care Act.

There’s an old saying about preventive medicine: “An ounce of prevention is worth a pound of cure.”

This obviously doesn’t work with actual weights, but it’s an accurate expression of value that holds true for health care today. Routine checkups and preventive services may help people avoid serious health problems and maintain their health. That’s why the Affordable Care Act contains a provision to make certain important preventive services available without having to pay copays, coinsurance or deductibles.

Some examples of preventive services covered by this provision include well baby and well child care, blood pressure, diabetes and cholesterol screening, screenings for health issues such as smoking, depression and alcohol abuse, routine vaccinations and immunizations, and even hearing screenings.

The provision also covers screening mammograms and screening colonoscopies. Sorry, no visual aids for those.

One important thing to note is that a procedure can be considered preventive care in some situations, but not in others. This is important, because a service has to be considered preventive in order to be exempt from copays, coinsurance or deductibles. If it’s not, these charges may apply.

To help make sense of this, let’s play a quick round of Preventive or Not Preventive? I’ll describe a situation, and you tell me whether or not it’s an example of preventive care. Yes, I know I can’t actually hear you, but just play along.

Here’s the first situation: A woman visits a doctor in her network for an annual mammogram. Preventive or Not Preventive?

SFX: Buzzer

The correct answer is Preventive, because her visit is part of a routine annual exam and not because she had a previous diagnosis. Seems simple enough, right? OK, how about this: A woman visits a doctor in her network for an annual mammogram, but the results prompt the doctor to ask her to come back in six months for a follow-up visit and a follow up mammogram.

SFX: Buzzer

In this case, the first mammogram is considered preventive, but the second is not. The second mammogram, which is done much sooner than a screening mammogram, and any additional tests would be considered treatment for a diagnosed condition.

Let’s try another one. A man receives a blood test to measure his cholesterol level at his annual wellness exam.

SFX: Buzzer

In this case, the office visit and the blood test are considered preventive care, because the patient who is being screened has no known symptoms, illness or injury.

With me so far? Let’s do one more. A man makes quarterly visits to his doctor for blood tests to check his cholesterol level and to confirm the medication dosage is appropriate.

SFX: Buzzer

Because they are part of a treatment regimen for an existing condition, the quarterly blood tests are not preventive care.

So, let’s review the basics and cover a few more considerations on preventive care:

The Affordable Care Act makes certain preventive services available to most plan members without copays, coinsurance or deductibles.

To be covered without member cost-sharing, the tests, examinations and other medical services must be preventive, and not part of a diagnostic procedure or ongoing treatment for an existing condition.

If a plan includes a network of providers, the elimination of copays, coinsurance and deductibles for certain preventive services applies only to in-network providers. In fact, some plans may not cover preventive services that are received out-of-network at all.

Vitamins, nutritional supplements, aspirin, over the counter medications, fitness classes and health club memberships are not considered preventive care services. These services are not covered at all.

Some “grandfathered” health plans are exempt from this provision.

While it’s long been said that one of these a day keeps the doctor away, taking advantage of routine preventive care services is a much better bet for long-term health and wellness.

To learn more about preventive care, including the health screenings and immunizations that are recommended for you, visit

If you have questions about your benefit plan, please call the toll-free number on the back of your health plan ID card.

“Mmm, oh. My heavens, that’s delicious. I feel better already.”