Since passage of the Affordable Care Act (ACA) in March 2010, the addition of preventative care benefits has been one of the principal selling points. However, the expectations of consumers did not match the benefits provided by health insurance carriers. The confusion led the Obama administration to issue guideline, provided on February 20, 2013, to clarify the benefits available to consumers under ACA.
The most significant area of confusion was regarding a colonoscopy, which the consumer typically believed was going to be covered completely by the health plan, including deductible, coinsurance and copays. The covered individual many times discovered this was not the case, and a large bill was proof that the procedure was not a covered benefit. What started as a preventative procedure covered by the health insurance carrier became a standard procedure not covered once the doctor identified and removed a polyp. Prior to clarification by the Department of Health and Human Services (HHS), the procedure would have been coded as a diagnostic procedure and not covered under the preventative care benefit. HHS has issued guidelines that removal of a precancerous growth during a colon cancer screening should be viewed as a preventative care procedure and covered as a preventative care benefit, which is paid 100% by the health insurance carrier with no deductible, coinsurance or copay.
In addition to preventative care benefits assigned to a colonoscopy, HHS issued additional guidelines strengthening preventative care benefits.
- Health plans that do not have contracted, in-network physicians to perform preventative care services should be required to provide preventative care benefits, with no deductible, coinsurance or copays, as if the physician was an in-network provider.
- Testing ordered by a physician to identify genes that increase the risk of breast cancer should now be classified as a preventative care benefit. The test commonly referred to as the BRCA gene test typically costs approximately $3,000, and insurance carriers would subject the test to deductible and coinsurance. Under the new HHS rules if a physician orders the test based on the patient’s family history, the test should be coded as preventative care with no deductible, coinsurance or copays.
- Over-the-counter medications written under a physician’s prescription such as aspirin for the treatment of a heart condition or nicotine replacement therapy for smoking cessation should be covered as a health insurance plan’s preventative care benefit.
- In order to comply with ACA’s mandate to provide preventative care benefits for contraception, health insurance carriers should have to provide benefits for a full range of FDA-approved methods in addition to birth control pills. Examples include long-term implants and intrauterine devices. Birth control methods to be used by men are still not covered as a preventative care benefit.
The guidelines issued by HHS are not formal regulations and do not carry the regulatory authority of law, but they exert pressure on the health insurance industry to comply or face additional, more stringent rules. The health insurance industry responded by stating that the new guidelines will result in higher premium costs because these benefits were not previously incorporated into the plan designs.
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