An ounce of prevention… well, you know the rest.
In medicine, prevention aims to detect problems before they become serious, affecting both the patient’s health and finances.
One of the most popular parts of the Affordable Care Act, which allows patients to get certain tests or treatments without paying money to cover copayments or deductibles, is based on this idea.
“There are still gaps to be filled,” said
Since late 2010, when this provision of the ACA went into effect, many patients have paid nothing when they have routine mammograms, receive one of more than a dozen vaccines, receive a contraceptive or are screened for other conditions, including diabetes, colon cancer, depression. and sexually transmitted diseases.
This can translate into big savings, especially when many of these tests can cost thousands of dollars.
Yet this popular provision comes with challenges and caveats, from an ongoing court case to
KHN spoke with several
experts to help guide consumers through this confusing landscape.
Their advice number 1: Always check with your own health insurance plan beforehand to make sure that a test, vaccine, procedure or service you need is covered and that you qualify for the benefit without cost sharing. And if you receive a bill from a doctor, clinic, or hospital that you think might be eligible for no-cost sharing, call your insurer to inquire or dispute the charges.
Here are five more things to know:
Insurance questions
The law covers most types of health insurance, such as ACA-qualified health plans that consumers purchased for themselves, employment-based insurance, Medicare, and Medicaid. Generally, pre-ACA health plans, which existed before
Not all preventative services are covered
The federal government currently lists 22 broad categories of coverage for adults, another 27 specifically for women, and 29 for children.
To appear on these lists, vaccines, screening tests, drugs and services must have been recommended by one of the four groups of medical experts. One of them is the
The task force, for example, recently recommended lowering the age for colon cancer screenings to include people between the ages of 45 and 49. This means more people won’t have to wait until their 50th birthday to avoid copays or franchises for screening.
Still, young people could be sidelined a bit longer if their health plan applies to the calendar year, which many do, because those plans aren’t technically required to comply until January.
This area is also one in which Medicare sets its own rules that may differ from the task force recommendations, said
Medicare covers stool tests or flexible sigmoidoscopies, which screened for colon cancer, with no cost sharing from age 50. There is no age limit for screening colonoscopies, although they are limited to once every 10 years for those at normal risk. Coverage of high-risk patients allows for more frequent screening.
Many of the task force recommendations are limited to very specific populations.
The task force, for example, recommended screening for abdominal aortic aneurysm only for men aged 65 to 75 with a history of smoking.
Others, including women, should get tested if their doctors think they have symptoms or are at risk. These tests could then be diagnostic rather than preventive, triggering a co-payment or deductible expense.
Possible limits
Insurers have leeway over what is allowed by the rules, but they have also been warned that they cannot be parsimonious.
The ACA defines the parameters. Federal guidelines say that smoking cessation programs, for example, must include coverage for medications, counseling, and up to two quit attempts per year.
With contraception, insurers must offer at least one copay-free option in most birth control categories, but are not required to cover every contraceptive product on the market without copays. Insurers might choose to focus on generics, for example, rather than branded products. (The law also allows employers to opt out of the birth control mandate.)
Expect challenges
When the ACA came into force, trouble spots emerged. There was a lot of drama around the colonoscopies.
Initially, patients found that they were charged copayments if polyps were discovered. But health regulators have put a stop to that, saying the removal of polyps is considered an essential part of the screening exam. These rules currently apply to commercial insurance and are still in effect for Medicare.
More recently, federal guidelines clarified that patients cannot be billed for colonoscopies ordered as a result of suspicious results on stool-based tests, such as those mailed to patients’ homes or colon exams. using CT scanners.
The rules apply to professional and other commercial insurance with one caveat: They come into effect for policies with plan years beginning in May, so some patients with calendar year coverage may not yet be included.
At this point, it will be “a gigantic victory,” said Dr.
But, he noted, Medicare is not included. He and others are urging Medicare to follow suit.
Such differences in payment rules depending on whether an examination is considered a diagnosis or a screening test are a problem for other types of tests, including mammograms.
This has recently been triggered
The previous test didn’t cost her anything, so she was stunned by her bill for more than
“They give me the same service and changed it to be diagnostic instead of screening,” Brewer said.
Keith from Georgetown pointed out a related complication: it may not be a specific development or symptom that triggers this change.
“If patients have a family history and need to get tested more frequently,” she said, “that’s often coded as a diagnosis.”
Vaccines and medications can be tricky too
Dozens of vaccines for children and adults, including those against chicken pox, measles and tetanus, are covered without cost sharing.
The same is true for some preventive medications, including some breast cancer drugs and statins for high cholesterol. Pre-exposure medications to prevent HIV, as well as much of the associated testing and follow-up care, are also covered free of charge for high-risk HIV-negative adults.
And after?
Overall, the ACA helped reduce out-of-pocket expenses for preventive care, Keith said. But, like almost everything else with the law, it has also drawn criticism.
Among them are conservatives opposed to some of the free services, who have taken legal action in a
A decision in this case, Kelley v. Becerra — the latest in a series of ACA challenges since it took effect — could come this summer and will likely be appealed.
If the final decision invalidates the preventive mandate, millions of patients, including those who buy their own insurance and those who obtain it through their work, could be affected.
“Each insurer or employer would be free to decide which preventative services to cover and whether to do so with cost sharing,” Keith said. “So even those who have not lost access to preventive services themselves might have to pay out of pocket for some or all of the preventive care.”
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