An ounce of prevention… well, you know the rest. In medicine, prevention aims to detect problems before they become serious, affecting both.
One of the most popular parts of the Affordable Care Act, which allows patients to get certain tests or treatments without shelling out money to cover co-payments or deductibles, is based on this idea.
“There are still gaps to fill,” said Katie Keith, a researcher at Georgetown University’s Center on Health Insurance Reforms. But, she said, the law has “unquestionably” made preventive care more affordable.
Since late 2010, when this ACA provision 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, a court case in Texas that could overthrow it, to complex and obtuse qualifiers that can limit its magnitude, leaving patients with medical bills.
KHN spoke to several experts to 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 charge.
Here are five more things to know:
1. Your insurance matters.
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 March 2010 and have not changed since, and most short-term or limited-benefit plans are not included. Medicare and Medicaid rules on who is eligible for which non-cost-sharing tests may differ from commercial insurance, and Medicare Advantage plans may in some cases have more generous coverage than the traditional federal program.
2. Not all preventative services are covered.
The federal government currently lists 22 major categories coverage for adults, an additional 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 US Preventive Services Task Force, a nongovernmental advisory group that assesses the potential benefits and harms of screening tests when used in the general population.
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 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 is also the area in which Medicare sets its own rules that may differ from the task force’s recommendations, said Anna Howard, access to care specialist at the American Cancer Society Cancer Action Network. 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.
For example, the task force 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.
3. There may be limits.
Insurers have leeway over what is allowed by the rules, but they have also been warned that they cannot be parsimonious.
California, for examplerecently cracked down on insurers who limited free testing for sexually transmitted diseases to once a year, saying that was not enough under state and federal laws.
The ACA defines certain parameters. Federal guidelines say smoking cessation programsfor example, must include coverage for medication, 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. For example, insurers might choose to focus on generics rather than branded products. (The law also allows employers to opt out of the birth control mandate.)
4. Certain tests – often the most expensive – present particular challenges that affect coverage determinations.
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 being introduced for health insurance.
More recently, federal direction clarified that patients cannot be ordered following suspicious findings 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. 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 depending on whether an examination isare a problem for other types of tests, including mammograms.
It tripped up Laura Brewer of Grass Valley, Calif., recently when she went for a mammogram and ultrasound in March, six months after a cyst was noticed during a previous exam by another radiologist. The previous test cost her nothing, so she was stunned by her bill of over $1,677 for procedures now considered diagnostic.
“They give me the same service and changed it to be diagnostic instead of screening,” Brewer said.
Keith, from Georgetown, pointed to 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, that’s often coded as a diagnosis,” she said.
5. Vaccines and medications can also be tricky.
Dozens of vaccines for children and adults, including those against chickenpox, 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 drugs to prevent HIV – along with much of the associated testing and follow-up care – is also covered at no cost for high-risk HIV-negative adults.
So what’s the next step?
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.
They include conservatives opposed to some of the free services, who have filed a lawsuit in a federal district court in Texas that, if successful, could strike down or restrict part of the law that does not provide for cost sharing. for preventive care.
A decision in this case, Kelley v. Becerra – the latest in a series of challenges to the ACA since it took effect – could take place 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.”
KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Along with policy analysis and polling, KHN is one of the three main operating programs of KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization providing information on health issues to the nation.