Ask an Advocate

Why did I have to pay for my preventive services?

You scheduled your annual checkup, expecting it to be covered in full—and then a bill showed up. So, what gives? Let’s break down what counts as preventive care and why you may still receive a charge even when you’re told it’s “Covered at 100%.”

What’s Usually Covered?

Most health plans cover certain preventive services at 100%, meaning you don’t owe anything out of pocket—as long as the visit stays strictly preventive. Covered services typically include:

• Annual physical exams: A head-to-toe assessment to monitor your overall health.
• Screenings: Tests like mammograms, colonoscopies, blood pressure checks, and cholesterol panels are typically covered at 100% for people in certain age brackets or risk categories—as long as they’re done for preventive reasons (not to diagnose symptoms).
• Immunizations: Routine vaccinations, like flu shots, Tdap, and shingles vaccines, are often covered for specific age groups and risk levels. However, coverage can vary depending on your plan and current guidelines.
• Preventive labs: Basic lab work like lipid panels and glucose tests are often covered, too. But some labs—like vitamin D or thyroid testing—aren’t considered preventive by most insurance plans and may be billed to you.
• Here is a list of commonly covered preventive labs.

Why Did I Still Get a Bill?

Even during a preventive visit, you may be charged if:

• You discussed new symptoms: Mentioning things like headaches, joint pain, or digestive issues can change the visit from preventive to diagnostic, which means your provider is treating a specific concern—and that may trigger a copay or deductible.
• Your provider ran extra tests: If labs or imaging go beyond what’s considered standard preventive care, you could be billed.
• You had a procedure done: Something like freezing a wart, draining fluid, or even an in-office EKG during your exam could be considered diagnostic.

The Bottom Line

Preventive care is a great way to stay ahead of potential health issues—but when your appointment includes diagnosis or treatment of a current problem, your health plan may treat it differently.

Tip: If you’re scheduling a wellness exam, let your provider know ahead of time that you want a preventive visit only. It’s also okay to ask them what might or might not be billed separately.

Still confused? We’re here to help. If you’re not sure whether a service should’ve been covered—or want help reading your bill—reach out to our Employee Advocacy Team by calling 855-662-1029 or emailing AdvocateServices@morrisgarritano.com