How do I get my California health plan to cover preventive care services, like check-ups and screenings, at no cost to me?

Under California and federal law, most health plans must cover specific preventive services at no cost when you use an in-network provider. This includes services like annual check-ups, immunizations, and various health screenings. Here is how to ensure your plan covers these services at no cost: Step 1: Confirm Your Provider is In-Network Before scheduling, use your health plan’s website or call its member services line to confirm your doctor or clinic is “in-network.” Using an out-of-network provider will result in you paying some or all of the cost. Step 2: Verify the Service is Covered Review the official list of covered preventive services for your age and gender. You can find these on the federal Healthcare.gov website or by requesting the list directly from your health plan. These lists are based on federal guidelines and include screenings, counseling, and immunizations. Step 3: Schedule a "Preventive Visit" When you call to make your appointment, be very specific. State that you are scheduling a "preventive care visit" or "annual wellness exam." This helps ensure the clinic bills your health plan using the correct code for a no-cost service. Step 4: Review Your Explanation of Benefits (EOB) After your visit, your health plan will send an EOB document. Review it carefully to confirm you were not charged a copay, deductible, or coinsurance for the preventive service itself. Step 5: Appeal Any Incorrect Charges If you are incorrectly billed, call your health plan’s member services department immediately to dispute the charge. If the phone call does not resolve the issue, you must file a formal written appeal. You generally have 180 days from the date of the denial to file. Keep copies of your EOB and all communications. Step 6: Escalate to the State Regulator If your plan denies your appeal, you can file a complaint with the appropriate California regulator. For most HMO and PPO plans, this is the Department of Managed Health Care (DMHC). For other insurance policies, contact the Department of Insurance (CDI). Important details and nuances: The no-cost rule applies only to the preventive service. If your check-up leads to the diagnosis or treatment of a separate health problem during the same visit, you may be billed for those additional services. Warnings and limitations: This requirement may not apply to older "grandfathered" health plans (created before March 23, 2010). Check your plan documents to determine if your plan is grandfathered. This is general information and does not constitute legal advice. For complex situations, consult with a qualified California attorney.