Charged for your annual physical? Why, and what to ask

You expected your yearly checkup to cost nothing, and now there is a bill. That is an upsetting surprise, and there can be ordinary reasons for it. This guide explains what most plans must cover, the usual ways a free visit gains a charge, and what to ask.

The short answer

Most health plans must cover a list of preventive services with no copay, coinsurance or deductible. HealthCare.gov says these services are generally covered at no cost when an in-network provider delivers them, and that $0 cost is not certain in all cases.

A bill after a physical usually comes from one of a few places. A problem was talked about during the visit and billed as its own office visit. A test or service was not on the preventive list. The provider was out of network. Or your plan is grandfathered. Each one is worth a question, and only the provider and your plan can say which one applies to you.

Is an annual physical free with insurance?

Often, but the rule is about specific services, not the word "physical." HealthCare.gov says these services are generally covered at no cost to you when provided by an in-network medical provider. The federal rule behind it, 45 CFR 147.130, says a plan must cover listed items and not impose cost sharing, such as a copayment, coinsurance or a deductible. The list includes items and services rated A or B by a national task force, routine immunizations, preventive care and screenings for infants, children and adolescents under national guidelines, and added preventive care and screenings for women under national guidelines.

So the question is not "was it a physical?" The better question is "which services in that visit were on the preventive list?" Your plan can tell you.

Why did a free checkup get a charge?

Here are the ways we found in the sources.

1. A problem was discussed, and the visit was billed as an office visit. The rule has an office visit section. If a preventive service is billed separately from an office visit, the plan may charge cost sharing for the office visit. If the preventive service is not billed separately, and the main purpose of the visit is not that service, the plan may also charge for the office visit. The rule gives an example: a person sees a provider about recurring stomach pain and gets a blood pressure screening. The plan may charge for the office visit. If the main purpose of the visit is the preventive service and it is not billed separately, the plan may not charge for the office visit.

This means two charges can sit side by side: a preventive part with no cost sharing and an office visit with cost sharing. It is worth asking what the visit was mainly for, and who decided.

2. A test or service was not preventive. The rule gives an example where a screening is found to point to a condition and treatment follows. The plan may charge for that treatment, because treatment is not on the preventive list. Ask which tests or services were added during the visit, and why.

3. The provider was out of network. The rule says a plan with a network does not have to cover these services from an out-of-network provider, and may charge cost sharing. If the plan has no in-network provider who can give the service, the plan must cover it from an out-of-network provider with no cost sharing. If you chose an in-network office but a lab or another provider involved was out of network, see our guide on a bill from a doctor you did not choose.

4. Your plan is grandfathered. The rule itself says the preventive coverage rules do not apply to grandfathered health plans. CMS describes these as plans in effect on March 23, 2010 that were not significantly changed afterward. Your plan documents or your employer's benefits office can tell you if yours is one.

A bill alone does not tell us which of these applies to you.