This article was last updated on Nov. 4, 2022.
We all know how important it is to have a primary care provider — also known as a personal doctor — and get regular preventive exams. It’s even been proven that regular preventive care leads to better health outcomes External Site in the long run.
But what is preventive care? And what should your benefits cover? It’s important to feel informed and empowered when you go into your next preventive exam, sometimes referred to as an annual wellness exam, to avoid unexpected costs down the road.
Our most frequently asked questions about preventive exams
What are preventive exams?
Medically speaking, preventive exams are performed in the absence of a medical condition or symptom. That just means, preventive exams, care or services can help avoid sickness or disease. Your doctor can help identify health conditions in their early stages when they are easier and less costly to treat. Preventive exams can include things like standard immunizations, blood pressure screenings, blood work, and depression screenings.
Are preventive exams free?
Almost all preventive exams are covered at no cost to you if you have health insurance. Be sure you log in to or register for myWellmark® Secure to know the basics of your specific health plan, what preventive benefits you haven't used yet and how those benefits work. For example, some plans require you to see the health care provider you've chosen as your primary care provider for preventive exams to be covered at 100 percent.
NEW: Not sure if you've used your annual preventive exam yet?
Wellmark members will now be alerted toward the end of their plan year if they still have an annual preventive exam remaining. After logging in to myWellmark, members with a remaining visit will see an alert in the Message Center letting them know this information.
How often are preventive exams covered?
Again, you should check your benefits Secure for specific coverage details. Most Wellmark Blue Cross and Blue Shield plans cover one preventive exam at zero member cost-share each annual benefit period. That means you don’t need to wait 365 days from one preventive exam to the next. For example, if your annual benefit period runs from January to December, you can have a preventive exam in November and again in April.
When does a preventive exam turn into a medical visit?
Sometimes, there is confusion about the difference between preventive care and diagnostic or medical care. If your health care provider discovers something during your exam, they may order additional testing. If this results in a diagnosis other than preventive care, the appointment could be billed as a medical visit where cost-share may apply. This may lead to out-of-pocket costs that you weren't expecting.
For example, let's say you went to your annual preventive exam. You and your health care provider talked about your personal and family health history, completed a physical exam and any immunizations you weren't up to date on, and did necessary bloodwork. At the same time, you talked to your health care provider about some knee pain you've been experiencing. Because of this conversation, another exam or procedure might be necessary, leading to potential cost to you. Remember, you can always talk to your health care provider or Wellmark if you are concerned about unexpected costs to find a solution that works for you. In the end, your health is the most important thing to prioritize.
What is covered at my visit?
Before your visit, check your benefits to understand what will and won’t be covered at your checkup. Wellmark has outlined a list of common preventive services PDF File that are covered under the Affordable Care Act (ACA). No matter what your specific plan covers, these are great screenings to keep in mind and discuss with your doctor:
- Annual wellness examination
- Colorectal cancer screening
- Depression screening
- High blood-pressure screening
At the end of the day, make sure you know the basics of your health plan and how it works. Don’t leave it up to your doctor to know the ins and outs. If you wait until you're in the exam room to ask questions about billing or costs, you could be in for a surprise. Call ahead and speak to a billing specialist to clear up any lingering questions you have about preventive services.
Wellmark members can call the customer service number on the back of your ID card or log in to myWellmark Opens New Window. You can even download the mobile app Opens New Window for easy, on-the-go access to tools and resources to make health insurance even easier.