Q. My doctor added on a charge for a “chronic disease management” appointment on top of my annual physical because I have thyroid disease and arthritis. The doctor’s office explained that my visit was more complicated than a routine physical. I’m not sure I buy that. In my case, it only cost a $20 copay, but I was surprised that it was billed that way, and it could be a surprise for someone without the excellent coverage that I have. Can they do that?
A. They may be able to do so. Under the health law, most health plans have to cover recommended preventive health care services without requiring consumers to pay anything out-of-pocket. The only exception is for plans that have maintained grandfathered status under the law.
The guidelines for women explicitly allow an annual well-woman visit for recommended preventive services. Coverage for annual physicals for men isn’t required under the law, but federal rules say that office visits that are primarily preventive in nature may be covered without any patient cost sharing, says Adam Sonfield, a senior public policy associate at the Guttmacher Institute who has written extensively about the law’s preventive coverage requirements.
If, in addition to a routine physical exam, your doctor also provides “evaluation and management” services or other higher level services related to your chronic conditions, you may be charged for that portion of the office visit, say primary care practice specialists. It will likely depend on whether the physician bills separately for those services in addition to the routine physical exam.
In your case, the extra charge was a $20 copay. But depending on how a health plan is structured, other people might be on the hook for a much larger charge. If a plan has an “all-inclusive” deductible, “the insurance coverage does not kick in until you meet it, meaning all other office visits, lab work [and the like] are subject to that deductible,” says Jennifer Tolbert, director of state health reform at the Kaiser Family Foundation. (KHN is an editorially independent program of the foundation.)
Of course, an argument can be made that managing someone’s chronic conditions is preventive.
“Clearly, for this person managing the chronic disease is really important, because it prevents a worsening of the disease,” says Sonfield. But not everyone agrees with that interpretation. Besides, if that’s considered prevention, “Where do you draw the line?”