What happens if you go out of network for preventative care?

All marketplace plans must cover certain preventive services. And they’re free of charge, as long as you use an in-network provider.

• For all adults: The 15 preventive services for adults include immunizations as well as screenings for depression, high blood pressure, colorectal cancer, and high cholesterol. Adults are also entitled to diet and alcohol-abuse counseling at no cost.
• For women: There are 22 preventive services offered to women at no charge. Well-woman visits include important checkups such as mammograms, cervical cancer screening, and birth control counseling. For pregnant women and their unborn babies, there are screenings for things like pregnancy-related diabetes and sexually transmitted diseases.There are also services for domestic violence victims.
• For kids: Children have access to 26 different preventive services, including many immunizations and a variety of screenings. Children under two, for example, may be screened for autism. And kids entering their teens may be screened for HIV, depression, and more.

Taking advantage of no-cost preventive care is a smart idea. It can help you and your doctor spot potential medical issues (hopefully before they become a big deal) or treat a condition before it blows up into something major. Chances are, in the long run you’ll not only feel better, you’ll save some cash on healthcare.

What Else You Need to Know

Not all plans are required to cover preventive services. If your plan is not a qualified health plan, you may be charged for preventive care and you may not be entitled to some services. Employer plans that are “grandfathered” often charge for many preventive benefits. Short-term medical and accident plans usually don’t include any cost-free preventive services. However, any plan you buy on a federal or state marketplace (or with a government-approved partner like GetInsured) will include free preventive care.

You must use an in-network provider or you could get hit with a big bill. If you go to an out of-network doctor or provider for your preventive services, you’ll probably be charged for the cost of the visit as well as the service, even if it’s on the list of covered benefits.

Even if you stay in-network, there’s a chance you might receive a bill if your provider orders additional tests beyond the covered preventive benefits. You’ll also be charged if the primary reason for your visit was not preventive care.