Aed prevention… well you know the rest. In medicine, prevention aims to detect problems before they get worse, affecting the patient’s health and money.
One of the most common parts of the Affordable Care Act, which allows patients to get it Some tests or treatments Without cashing in to cover co-payments or discounts, based on that idea.
“There are still some gaps that need to be filled,” said Katie Keith, a researcher with the Center for Health Insurance Reforms at Georgetown University. But, she said, the law made preventive care affordable “undoubtedly”.
Since late 2010, when this ruling from the ACA took effect, many patients have paid nothing when they undergo routine mammograms, get one of more than a dozen vaccinations, receive contraceptives, or are screened for other conditions. These include diabetes, colon cancer, depression and sexually transmitted diseases.
This can translate into significant savings, especially when many of these tests cost thousands of dollars.
However, this common ruling comes with challenges and warnings, from an ongoing lawsuit in Texas that might overturn it, to complex and separate clauses that can limit its breadth, leaving patients with medical bills.
KHN has spoken with several experts to help guide consumers through this confusing landscape.
Tip 1: Always check with your health plan in advance to make sure the test, vaccine, procedure, or service you need is covered and that you qualify for the no-cost-sharing benefit. And if you get a bill from a doctor, clinic, or hospital that you think qualifies for not sharing costs, contact your insurance company to inquire about or dispute the charges.
Here are five more things to know:
1. Your insurance matters.
Most types of health insurance are covered by law, such as ACA-qualified health plans that consumers purchase for themselves, work-based insurance, Medicare, and Medicare. Legacy health plans prior to the ACA, which existed before March 2010 and have not changed since then, are generally not included, and most plans are short-term or limited in benefits. Medicare and Medicaid rules about who qualifies for tests without cost-sharing may differ from those of commercial insurance, and Medicare Advantage plans may in some cases be more generous than a traditional federal program.
2. Not all preventive services are covered.
Currently the federal government Lists 22 broad categories For adults, an additional 27 for women specifically, and 29 for children.
To get these lists, you must have been recommended by one of the four groups of medical experts for vaccines, screening tests, medications, and services. One of these is the US Preventive Services Task Force, a nongovernmental advisory group that weighs the potential benefits and drawbacks 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 that more people won’t have to wait for their fiftieth birthday to skip subscriptions or discounts to check out. However, younger people may be disqualified for a little longer if their health plan applies to a calendar year, which many do, as these plans are not technically required to comply until January.
This area is also one of the areas where Medicare is located He makes his own rules That may differ from the task force’s recommendations, said Anna Howard, an access to care specialist at the American Cancer Society’s Cancer Control Network. Medicare covers stool tests or flexible sigmoidoscopy, which screen for colon cancer, without sharing the cost starting at age 50. There is no age limit for colonoscopy screening, although it is limited to once every 10 years for people at normal risk. Coverage allows high-risk patients to have more frequent screening.
Many of the Task Force’s recommendations are limited to very specific population groups.
For example, the task force recommended screening for abdominal aortic aneurysms only for men aged 65 to 75 years with a history of smoking.
Others, including women, should get tested if their doctors think they have symptoms or are at risk. These tests can then be diagnostic, not preventive, resulting in a co-pay or a deductible fee.
3. There can be limits.
Insurers have leeway as to what’s allowed under the rules, but they’ve also been warned that they can’t be stingy.
California, for exampleIt recently cracked down on insurance companies that were limiting free STD tests to once a year, saying that was insufficient under state and federal laws.
The ACA sets the parameters. Federal directive says Smoking cessation programsfor example, should include coverage for medication, counseling, and up to two attempts to quit smoking in a year.
With contraception, insurers must offer at least one no-subscription option in most birth control classes, but they are not required to cover every contraceptive product on the market without a subscription charge. For example, insurance companies can choose to focus on generic drugs rather than brand-name products. (The law also allows employers to opt out of birth control jurisdiction.)
4. Some tests – often very expensive – have special challenges that affect the determination of coverage.
When the ACA came into effect, trouble spots appeared. There has been a lot of drama around colonoscopy. Initially, patients found that they were billed for co-payments if polyps were found. But health regulators have held it back, saying removing polyps is an essential part of the screening test. those rules It currently applies to commercial insurance and is still in the process of getting Medicare.
at recent days, Federal directive He made it clear that patients could not be charged to have a required colonoscopy after suspicious results on stool-based tests, such as those mailed to patients’ homes, or colon scans using computed tomography (CT) machines.
The rules apply to job-based and other commercial insurance with one caveat: These rules go into effect for policies whose plan years begin in May, so some patients with calendar year coverage may not be included.
At this 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 that Medicare is not included. He and others are urging Medicare to do the same.
Such differences in payment rules based on whether the test is considered diagnostic or a screening test are problematic for other types of tests, including mammograms.
This recently caused Laura Brewer of Grass Valley, Calif., to stumble when she went for a mammogram and ultrasound in March, six months after she noticed a cyst on a previous exam by a different radiologist. The previous test cost her nothing, so she billed her more than $1,677 for procedures now considered diagnostic.
“They gave me the same service and changed it to diagnosis instead of screening,” Brewer said.
Keith of Georgetown University pointed out one related complication: It may not be a specific development or symptom that leads to that change. “If patients have a family history and need to be tested more frequently, this is often coded as a diagnosis,” she said.
5. Vaccines and medications can be deceiving, too.
Dozens of vaccinations for children and adults, including chickenpox, measles and tetanus, covered Without cost sharing. So are some preventative medications, including some breast cancer drugs and statins for high cholesterol. pre-exposure Medicines to prevent HIV Along with a lot of related testing and follow-up care, it’s also covered at no cost for high-risk non-HIV adults.
So what’s next?
Overall, the ACA has helped reduce out-of-pocket costs of preventive care, Keith said. But, like almost everything else with the law, it has also attracted critics.
Among them are conservatives opposed to some free services, who have filed the suit in federal district court in Texas, which, if prevailing, could repeal or limit the part of the law that does not provide for cost-sharing for preventive care.
judgment in this case, Kelly vs Becerra The latest in a series of challenges facing the ACA since it came into force, it may come this summer and is likely to resume.
If the final decision invalidates the protective mandate, millions of patients could be affected, including those who buy their own insurance and those who get it through their jobs.
“Each insurance company or business owner will be left to decide which preventive services to cover and whether to do so through cost-sharing,” Keith said. “So even those who have not lost access to preventive services themselves may have to pay out of pocket for all or some 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 survey, KHN is one of the three major drivers in KFF (Caesar Family Foundation). KFF is a non-profit organization that provides information on health issues to the nation.
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