My deductible plan and the routine exam

Apple - Creative Commons - attribute: Dirk Haun Posted on October 10, 2012 

The first year that I had a high deductible plan, I was very cautious about going to the doctor and getting prescriptions filled. I saved money in a health savings account for any medical expenses, expected or unexpected.

I crossed my fingers that the "apple a day" truism would work for me.

When it came time for my annual physical, I expected that this visit would be free for me, since routine physicals have no copay and aren’t subject to the deductible. Simple, right?

Unfortunately there’s nothing simple when deductibles are involved. Despite working for the health plan, the topic is still confusing to me. There are many pieces of the health insurance “pie,” and on top of that, there are major changes happening nationally right now. Consumers are being asked to have more responsibility in decision making. As we adjust and learn, it’s understandable that there’s confusion.

So what will I pay for at my routine physical?

When I asked an expert here at FCHP about what I’d pay when I went to my physical, she told me that the situations vary from person to person. That, basically, there is no copayment for a routine annual exam because most of what’s done during the exam is routine, or preventive.

But there are scenarios where a routine visit might not be “free.” If I have anything done at the exam that’s not defined as “routine,” I would need to pay for those (until I meet my deductible), as mandated by health care regulations.

So if during my physical I said I had a sore throat, the doctor might do tests to diagnose the problem. Because that’s a diagnostic service, I would get billed for that.

Or, say I had a chronic illness, like diabetes. I may need lab work done to make sure that my levels are within manageable ranges, and I would pay for that service out of pocket, too. The lab work might be routine and preventive to me, but they’re not considered preventive by the standard list of preventive services that FCHP -- and now the entire country as part of the Affordable Care Act -- uses as a guideline.

It’s not as bad as it sounds, though. The provider will charge for tests, but FCHP usually gives members a significant discount on these charges, which is what you pay to the provider.

Communication is key

To learn more about what you may pay (if anything) during your exam, the best practice is communication.

  • Talk to your doctor at your visit. Let him or her know that you have a plan with a high deductible, and you want to know, to the best of their knowledge, if you’ll get charged for any part of the visit.

  • Ask about the lab work and tests that you get at your visit. Find out if they’re preventive or diagnostic, and if they’re medically necessary.

  • If you do need a test that is subject to the deductible and you get the bill for it, wait until you get your health benefits statement from us in the mail before writing a check to the provider. Even though you pay out of pocket for the blood work or a lab test, the amount you owe is the amount that FCHP has agreed with the provider as a reasonable amount – often, this is less than the original amount. Your health benefits statement will show you the amount you owe.

Here to help

Health care has changed, and the changes are still happening. Even though it’s a complex, multi-layered system, you’re not alone in it. People are here to help you, like the great expert I talked to about my plan.

You can reach an expert at FCHP at the telephone number above on this page if you need clarification, too.

Here’s to your health!

Blogged by Katie Crommett

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The information written about in this blog is not intended to be medical advice. Please seek care from a medical professional when you have a health concern.