Before December 31: 5 Visits to Book While Your Benefits Still Count

Introduction

The last weeks of the year are busy. Holidays, travel, and work deadlines crowd the calendar, and a doctor's visit is easy to push to "after the new year." But for many people, waiting until January makes the same care cost more.

That is because many health plans run on the calendar year. On January 1, the money you have paid toward your deductible goes back to zero. So does your progress toward your out-of-pocket maximum. If you have a flexible spending account (FSA), the balance you set aside may be gone too. The weeks before December 31 can be the cheapest time all year to take care of your health.

At Morningside Medical, we want you to get full value from the coverage you already pay for. In this article, we explain which parts of your plan reset, five visits worth booking before they do, and how to check your own plan in about ten minutes.

What Resets When Your Plan Year Ends?

Before you book anything, it helps to know which parts of your plan start over. Here are the three that matter most.

Your deductible

Your deductible is the amount you pay for covered care before your plan starts to share the cost. If your deductible is $2,000 and you have already paid $1,600 this year, you only have $400 left before your plan pays more. On January 1, you are back at $2,000.

If you have had a surgery, a hospital stay, an imaging test, or a lot of visits this year, you may have already met your deductible. That means more of your care now costs you only a copay or coinsurance.

Your out-of-pocket maximum

Your out-of-pocket maximum is the most you will pay for covered, in-network care in a plan year. After you reach it, your plan pays 100% of covered in-network costs for the rest of that year. Your monthly premiums do not count toward it. If you have reached it, covered care through December 31 may cost you nothing. That changes on January 1.

Your FSA balance

A flexible spending account lets you set aside money from your paycheck, before taxes, for health costs. The catch is the deadline. According to HealthCare.gov, you generally must use the money within the plan year, and you lose any money left over. Some employers give you a grace period of up to 2½ extra months. Others let you carry over a limited amount. They cannot offer both, and they do not have to offer either.

FSA dollars can pay for copays, coinsurance, and deductible costs at a visit. If you have money left, a visit before your deadline puts it to work instead of losing it.

A health savings account (HSA) is different. According to the IRS, money left in an HSA at the end of the year generally carries over to the next year, so there is no year-end deadline. If you are not sure which one you have, check your benefits portal or the card you use to pay for care.

Visit 1: Your Annual Physical or Well-Woman Visit

If you only book one visit this season, make it this one.

Most health plans must cover a set of preventive services at no cost to you, as long as you see an in-network clinician. That rule comes from the Affordable Care Act, and HealthCare.gov explains it in plain terms. For adults, most plans cover a yearly preventive visit (often called an annual physical), along with many screenings and vaccines. For women, preventive care also includes a well-woman visit, which can cover a Pap test or HPV test when you are due.

Plans count "yearly" in two ways, and the difference matters right now:

• Once per calendar year. If you have not had a physical since January, you still have one covered visit left. If you skip it, it does not roll over.
• Once every 12 months. You need about a year between visits. If your last physical was in early December, a visit now may be too soon.

Your plan documents or member services line can tell you which rule applies to you.

A physical is a chance to check your blood pressure and cholesterol numbers, review your medicines, and catch up on screenings. Our annual physical checklist explains what to bring. If you want to know why the visit matters even when you feel well, read why you need an annual physical.

One honest note about cost: a preventive visit is about prevention. If you bring up a new problem, like back pain or a rash, and your clinician treats it, your plan may bill that part as a regular visit. Some lab tests may also be billed separately. That is normal, and it is not a mistake. If cost is a concern, tell us at the start of the visit so we can plan the time together.

Visit 2: The Follow-Up for an Ongoing Condition

If you live with high blood pressure, diabetes, prediabetes, thyroid disease, asthma, arthritis, or another long-term condition, you likely need regular check-ins. These visits are where your care plan gets adjusted. Your clinician may change a dose, order labs, or refill a prescription.

Follow-up visits are not usually free under preventive care rules. That is exactly why timing matters. If you have already met your deductible, a follow-up in December may cost much less than the same visit in February.

A good follow-up visit covers:

• Your numbers. Blood pressure, blood sugar or A1C, cholesterol, and kidney function, depending on your condition.
• Your medicines. Whether they are working, any side effects, and whether you need refills to carry you into the new year.
• Your labs. Blood work that is due, ordered while your current cost-sharing still applies.
• Your plan for next year. What to watch for and when to come back.

If you were told to come back "in three months" and that was last summer, this is your sign to book. If you have prediabetes, regular check-ins help you see whether the changes you are making are working, while there is still time to keep type 2 diabetes from developing.

Many follow-ups can happen by telehealth, which can make a busy December easier.

Visit 3: Your Child's Well-Child Check-Up

Children need regular check-ups as they grow. Babies and toddlers need several visits a year. From age 3 on, the American Academy of Pediatrics recommends one well-child visit each year. Like an adult physical, a well-child visit is preventive care, so most plans cover it at no cost to you when you see an in-network clinician.

Winter break can be a good time to fit one in. School is out, and you can take care of forms and vaccines before the new term. A well-child visit checks growth and development, vision and hearing, and the vaccines your child needs to stay on schedule for school.

Our well-child check-up schedule shows which visits happen at which ages and what to expect at each one. Regular check-ups also help families avoid trips to the emergency room by catching small problems early.

If your child's last check-up was more than a year ago, book now. Year-end and back-to-school weeks tend to fill fastest.

Visit 4: The Specialist Visit You Keep Putting Off

Many people carry a health question for months. A joint that stays swollen. Morning stiffness that lasts. A blood test result, like a positive ANA, that a clinician said to "look into." These are the visits that slide from one season to the next.

If you have already met your deductible, a specialist visit before the year ends may cost far less than one in the spring. And for some conditions, earlier care makes a real difference. For inflammatory arthritis, for example, treatment that starts sooner can help protect joints over time.

At Morningside, new rheumatology patients are being seen now. If you are not sure whether your symptoms call for a specialist, our guide on when to see a rheumatologist can help. You can also learn more about our rheumatology care.

Before you book, check two things with your plan:

• Do you need a referral? Many HMO plans require a referral from your primary care clinician before you see a specialist. PPO plans often do not.
• Does the test or treatment need prior approval? Some imaging, tests, and medicines need your plan's approval first. Our article on prior authorization explains how that process works and how long it can take.

If you need a referral, start with your primary care visit. That way, the referral is in place and you are not waiting into the new year.

Visit 5: For Medicare Patients, the Annual Wellness Visit

If you have Medicare, your yearly preventive visit works a little differently.

Medicare covers a yearly Annual Wellness Visit once every 12 months. According to Medicare.gov, you pay nothing for this visit if your clinician accepts assignment, and the Part B deductible does not apply. Your first one cannot happen within 12 months of your Part B enrollment or your "Welcome to Medicare" visit.

The Annual Wellness Visit is a planning visit. You and your clinician review your health history, your medicines, and your risks, and you build a personalized prevention plan. It is not the same as a full head-to-toe physical. If your clinician also does tests or services that Medicare does not cover as part of the visit, Medicare.gov notes you may have to pay for them.

Because the Annual Wellness Visit runs on a 12-month cycle, it does not reset on January 1. But your Part B deductible does. So if you also need a follow-up visit, labs, or a specialist visit, booking them before the year ends can still save you money. Morningside accepts Medicare.

Don't Forget Your Vaccines

Vaccines are easy to forget, and many are covered as preventive care. Your needs change with age, health, and work. Adults often need a yearly flu shot, a tetanus booster every 10 years, and, depending on age, vaccines for shingles, pneumonia, and RSV.

Our adult vaccine schedule lists which vaccines are recommended at each age. Our article on why adult vaccine needs change with age explains the reasons behind them. Ask your clinician at any visit which vaccines you are due for.

How to Check Your Plan in 10 Minutes

You do not need to read your whole benefits booklet. Log in to your health plan's website or app, or call the member services number on the back of your card. Then find these answers:

1. When does my plan year end? Many plans end December 31. Some employer plans end on a different date, such as June 30.
2. How much of my deductible have I met? Many member portals show this on the home screen.
3. Have I reached my out-of-pocket maximum? If so, covered care may cost nothing until your plan year ends.
4. When was my last covered physical? And does my plan count "yearly" by calendar year or by 12 months?
5. Do I have an FSA, and what is my deadline? Check whether your employer offers a grace period or a carryover.
6. Do I need a referral to see a specialist?
7. Is Morningside in my network?

If you are not sure how to read your insurance card, our insurance card guide walks you through it. If you have a high-deductible plan, our guide to navigating high-deductible health plans explains how to plan your costs.

About your network: Morningside is in network with many plans, including Aetna, Anthem Blue Cross and Blue Shield, Cigna, EmblemHealth, Fidelis Care, Medicare, NYCE PPO, and UnitedHealthcare. Some plans limit which clinicians you can see, so please confirm your coverage before your visit. You can see the full, current list on our insurance and pricing page. If you are paying for care yourself, ask us about payment plans.

Book Early: December Fills Up

Many people realize in mid-December that their benefits are about to reset, so the last weeks of the year tend to be busy for doctor's offices. The earlier you book, the more times you have to choose from.

Our Harlem office is open Monday through Thursday, 8 a.m. to 6 p.m., and Friday, 9 a.m. to 5 p.m. We are closed on weekends. Same-day visits are available during all open hours, including for new patients. All of our clinicians are accepting new patients, and Spanish translation is available.

Frequently Asked Questions

Is my annual physical really free?

For most plans, yes, when you see an in-network clinician. The Affordable Care Act requires most health plans to cover preventive care at no cost to you, and most plans include a yearly preventive visit. If your clinician treats a new problem during the visit, or orders certain lab tests, those parts may be billed. Check your plan if you are not sure.

Can I have a physical in December and another one in January?

It depends on how your plan counts "yearly." If your plan covers one physical per calendar year, a December visit and a January visit can both be covered. If it covers one every 12 months, the January visit would likely be too soon. Your member services line can tell you which rule applies.

What happens to my FSA money if I don't use it?

In most cases, you lose it. Some employers offer a grace period of up to 2½ extra months, or let you carry over a limited amount to the next year. They can offer one or the other, not both. HSA money does not expire.

My plan year doesn't end in December. Does this still apply?

Yes, on your schedule. The same ideas apply to whatever date your plan year ends. Check your benefits portal for the exact date, then plan your visits before it.

Do I need to be a current patient to book?

No. All Morningside clinicians are accepting new patients, and same-day visits are available for new and current patients during all open hours.

How Morningside Can Help

Using your benefits well does not mean getting extra care. It means getting the care you already need at the time it costs you the least. For many people, that time is now.

At Morningside Medical, we offer adult primary care, women's health, pediatrics, and rheumatology under one roof, along with same-day care and telehealth. Whether you need a physical, a follow-up, a well-child visit, or a specialist visit you have been putting off, we can help you fit it in before your plan year ends.

You're always welcome to schedule a visit. Book your appointment today.

This article is for general information and is not a substitute for professional medical advice. Talk to your clinician about your specific situation. Coverage rules vary by plan, so check with your insurer about your own benefits.