One ounce of resistance … well, you know the rest. In medicine, the goal of prevention is to identify problems before they get worse, which affects both the patient’s health and finances.
One of the more popular parts of the Affordable Care Act, which allows patients to receive specific tests or treatments without having to spend cash to cover copement or deductible, is based on that concept.
“There are still gaps that need to be filled,” said Katie Keith, a researcher at Georgetown University’s Center on Health Insurance Reforms. But, he said, the law has “undoubtedly” made preventive care more affordable.
In late 2010, when this provision of the ACA came into force, many patients paid nothing when they had regular mammograms, more than a dozen vaccines, birth control, or screenings for other conditions, including diabetes, colon cancer. Depression, and sexually transmitted diseases.
This can translate into huge savings, especially when many of these tests can cost thousands of dollars.
Yet this popular provision comes with challenge and caution, starting with an ongoing court case in Texas that could overturn it, with complex and vague qualifications that could limit its breadth, including patients ’medical bills.
KHN has spoken with a number of experts to help guide consumers through this confusing landscape.
Tip # 1: Always check your own health plan in advance to make sure your test covers a test, vaccine, procedure, or service you need and that you are eligible for a cost-sharing facility. And, if you receive a bill from a physician, clinic, or hospital that you think may be eligible to share any costs, call your insurer to ask or discuss the charges.
Here are five more things to know:
1. Your insurance is important.
The law covers most types of health insurance, such as qualified health plans under the ACA that customers have purchased for themselves, job-based insurance, Medicare and Medicaid. Usually does not include pre-ACA legacy health plans, which existed before March 2010 and have not changed since, and most are short-term or limited-benefit plans. Medicare and Medicaid rules may differ from commercial insurances for any tests without cost sharing, and in some cases Medicare Advantage plans may have more generous coverage than traditional federal programs.
2. Not all preventive services are covered.
The federal government currently lists 22 broad categories of coverage for adults, an additional 27 specifically for women and 29 for children.
To get these lists, vaccines, screening tests, medications and services must be recommended by one of the four groups of medical experts. One of these is the US Preventive Services Task Force, a private advisory group that considers the advantages and disadvantages of screening tests when used among the general public.
For example, the task force recently recommended lowering the age for colon cancer screening to include people aged 45 to 49. This means more people don’t have to wait for their 50th birthday to avoid a copy or clearance for a screening. Still, young people can be left out a bit more if their health plans apply for calendar years, which many do, as those plans are not technically required to be complied with until January.
Anna Howard, a care access specialist at the American Cancer Society Cancer Action Network, said the area is also one where Medicare sets its own rules that may differ from the task force’s recommendations. Medicare covers stool testing or flexible sigmoidoscopy, which screens for colon cancer, starting at age 50 without cost sharing. There is no age limit for screening for colonoscopy, although it is limited to once every 10 years for people at general risk. Coverage for high-risk patients allows for more frequent screening.
Many of the recommendations of the task force are limited to very specific populations.
For example, the task force recommended screening for abdominal aortic aneurysms only for men aged 65 to 75 with a history of smoking.
Others, including women, should be tested if their doctors think they have symptoms or are at risk. Such tests can be diagnostic rather than preventive, triggering a co-payable or deductible charge.
3. There may be limits.
Insurers have made concessions on what is permitted under the rules, but have been warned that they cannot be trivialized.
California, for example, recently cracked down on insurers who were limited to free testing for sexually transmitted diseases once a year, saying it was not sufficient under state and federal law.
Sets the ACA parameter. Federal guidelines say that smoking cessation programs, for example, must include coverage for medications, counseling, and up to two quitting efforts each year.
With contraception, insurers must offer at least one option without a copy in most birth control departments but there is no need to cover every single contraceptive product on the market without a copy. For example, insurers may focus on generics rather than brand-name products. (The law allows employers to opt out of birth control mandates.)
4. Some tests – often expensive – have special challenges that affect coverage determination.
As soon as the ACA became effective, there were problems. There was a lot of drama surrounding the colonoscopy. Initially, patients saw that if polyps were found they were billed for co-payment. But health regulators have stopped it, saying polyp removal is considered an essential part of screening tests. These rules currently apply to commercial insurance and are still being phased out for Medicare.
Most recently, federal guidelines have clarified that patients cannot be charged for ordered colonoscopy after questionable results in stool-based tests, such as patients being mailed home, or having a colon examined using a CT scanner.
The rules apply to job-based and other commercial insurance with a caution: they apply to policies that start planning in May of the year, so some patients with calendar-year coverage may not be included yet.
At that point, it would be “a huge win,” said Dr. Mark Fendrick, director of the Center for Value-Based Insurance Design at the University of Michigan.
But, he noted, Medicare is not included. He and others are urging Medicare to follow suit.
Such differences in payment rules based on whether a test is considered a diagnostic or screening test are a problem for other types of tests, including mammograms.
This recently confused Laura Brewer of Grass Valley, California, when she went for a mammogram and ultrasound in March, six months after a different radiologist noticed a cyst in a previous test. The previous test did not cost him anything, so he was shocked to see a bill of more than $ 1,677 for a procedure now considered diagnostic.
“They’re giving me the same service and changing it to diagnostic instead of screening,” Brewer said.
Keith of Georgetown points out a related complication: it may not be a specific development or symptom that triggers that change. “If patients have a family history and need to be examined more frequently, it is often coded as diagnostic,” he said.
5. Vaccines and medicines can also be difficult
Dozens of vaccines for children and adults, including chickenpox, measles and tetanus, have been covered without cost sharing. So are some medications for breast cancer and some preventative medications, including high cholesterol statins. Pre-exposure drugs for HIV prevention – along with many related tests and follow-up care – are covered at no cost to high-risk HIV-negative adults.
So what next?
Overall, the ACA has helped reduce out-of-pocket costs for preventive care, Keith says. But, like almost everything else with the law, it has also attracted critics.
They include some conservatives who oppose free service, who have filed a lawsuit in a federal district court in Texas that, if overturned, could overturn or restrict parts of the law that do not share any costs for preventive care.
In that case the verdict, Kelly vs. Bessera – The latest in a series of ACA challenges since it went into effect – may come this summer and will likely be appealed.
If the final decision invalidates the restraining order, millions of patients, including those who buy their own insurance and those who receive it through their jobs, could be affected.
“Every insurer or employer will be left to decide whether to cover any preventive services and do so by sharing the cost,” Keith said. “So even those who have not lost access to preventive services may have to pay out of pocket for all or some preventive care.”
KHN (Kaiser Health News) is a national newsroom that creates in-depth journalism about health issues. KHN is one of the three major operating programs of KFF (Kaiser Family Foundation), including policy analysis and polling. KFF is a non-profit organization that provides health information to the nation.
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