The health plan selection conversation is progressing as usual. An agent has a potential client on the phone, and at this point, the agent has recorded the vital details needed to purchase health insurance through the healthcare.gov portal. The next step is to generate a quote for a potential client, and BAM! The cheapest quote is $150 per month and the Deductible is high (over $4000).
The conversation gets awkward at this juncture. The potential client will comment about how silly it is to pay full price for medical services before $4,000. Most clients in this situation feel jaded because, in this case, the plan still costs $150 per month. Why pay $150 per month if the plan really offers no financial assistance in medical costs before spending $4,000?
This is a valid point, believe me. It is hard to answer a tough question like this, but today, I have done my research, and I am prepared to give a comprehensive answer. Here it goes.
All marketplace plans offer “No-Cost Preventative Services.” I used to answer that this means that all people insured through a marketplace health plan have the benefit of seeing a doctor for wellness visits at no charge. This does include yearly check-ups, physicals, mammograms and colonoscopies, but I realize that this does not cover half of the services that doctors provide.
So what other preventative services are covered at no-cost?
Mothers: does your child need his immunization shots? Hepatitis A & B shots are covered at no charge. Flu shots, Tetanus shots, and vaccinations against Measles, Mumps and Rubella—are covered at no-cost under any marketplace health plan. For a complete list of the covered vaccinations, see the table below:
| Immunization Vaccine | Charge |
| Diptheria, Tetanus, Pertussis | No-Cost |
| Haemophilus Influenzae type b | No-Cost |
| Hepatitis A | No-Cost |
| Hepatitis B | No-Cost |
| Human Papillomavirus (HPV) | No-Cost |
| Inactivated Poliovirus (Polio Vaccine) | No-Cost |
| Influenza (Flu Shot) | No-Cost |
| Measles, Mumps, Rubella | No-Cost |
| Meningococcal | No-Cost |
| Pneumococcal | No-Cost |
| Rotavirus | No-Cost |
| Varicella | No-Cost |
Adults: Children are not the only ones who have access to the above vaccinations at no-cost. If you are an adult, your health plan covers all of the above shots except for the Haemophilus Influenzae type b vaccination. In addition, adults have access to the Herpes Zoster vaccination.
Vaccinations are only some of preventative services that a marketplace health insurance plan covers. Is there a history of Hypertension in your family? How about Type II Diabetes? If you are worried about developing the two previously mentioned conditions, then go see your primary care physician. He can screen for these conditions and others at no-cost. Here’s a full list of screening services:
| Screening Service | Cost |
| Blood Pressure Screening | No-Cost |
| Cholesterol Screening | No-Cost |
| Colorectal Cancer Screening | No-Cost |
| Depression Screening | No-Cost |
| Type II Diabetes Screening | No-Cost |
| Obesity Screening | No-Cost |
Sexually-Transmitted Disease Screening: If you are sexually active, or if you plan to be, then you should know about the preventative healthcare services offered under your marketplace plan. As you may or may not know, there are many infections that spread through sexual intercourse. These infections are classified as STIs, and common examples of these sicknesses include Gonorrhea, Chlamydia, Syphilis and HIV. This site is a great resource for the infections, and it addresses the common symptoms. If you are experiencing any of the symptoms listed in the site, don’t hesitate to see a doctor for a free screening. Here is a list of covered preventative reproductive health services.
| Screening Service | Cost |
| Chlamydia Infection Screening (Women Only) | No-Cost |
| HIV Screening | No-Cost |
| Gonorrhea Screening | No-Cost |
| Syphilis Screening | No-Cost |
Women: Many preventative services under Marketplace plans are for women only. For example, a Well-woman visit features clinical breast exams, pap tests and birth control consultation. These are clinical tests that only apply to women, but a complete list of women-only preventative health services can be found below.
| Preventative Service | Cost |
| Breast Cancer Services (Mammograms, BRCA) | No-Cost |
| Anemia Screening | No-Cost |
| Cervical Cancer Screening | No-Cost |
| Folic Acid Supplements | No-Cost |
| HPV DNA Testing | No-Cost |
| Osteoporosis Screening | No-Cost |
| Urinary Tract Screening | No-Cost |
| Well-woman Visits | No-Cost |
The Difference Between Preventative and Diagnostic Care
It is important at this point to distinguish between Preventative and Diagnostic Care. Preventative care is medical care aimed at preventing sickness. For example, physicians recommend that men regularly undergo colorectal cancer screenings starting at age 50. If a man goes in for a colonoscopy at age 50, and the doctor finds no cancer in the man’s colorectal tract, then the test would be classified as preventative, and the man would incur no charge from his health insurance company.
Let’s say another man went to see his primary care physician over rectal bleeding. The primary care doctor sends the man to see the gastroenterologist, and the gastroenterologist determines the cause for the rectal bleeding. The doctor treats the man for the condition, and the test is no longer a “no-cost” preventative service. If the doctor treats a condition, then he or she will charge. The insured will have to pay the full price if he or she has a high deductible health plan.
Conclusion
You’re right. If you purchase a plan with a high deductible, then it will probably be a while before your plan pays benefits. You might not ever get benefits from your carrier such as coinsurance on doctor visits, or coinsurance on prescription drugs. Shoot, you might never receive any benefits. It probably doesn’t help that you have to pay a monthly premium to keep the plan that may or may not pay benefits in the future.
But before you write the health plan off as a “rip-off” or “waste of money,” reconsider the many preventative health services that marketplace health plans offer at no-cost. Mothers—your children’s immunizations—Hepatitis A & B, Flu Shots—are covered at no cost. Adults—you have access to all of the immunization shots children have; plus, you have a laundry list of preventative services provided at no-cost to you—colorectal cancer screenings, blood pressure screenings.
Finally, be advised that you may incur some costs unexpectedly. If a doctor finds something that must be treated, then he will order diagnostic tests. Diagnostic tests are aimed at treating medical conditions, and if a doctor treats a condition, the patient is on the line for the full cost of the service in most cases with a high deductible health plan.
Philip Strang is an enrollment specialist at American Exchange, and is a Marketplace Certified Agent/Broker. To contact him with any questions or comments you can email him at p.strang@americanexchange.com or call at 1-888-995-1674.
