The ACA eliminated co-pays for preventive care. So why are some doctors still making us pay?
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You’re not alone.
This confusion is causing providers to charge for services that should be free, encouraging patients to demand
treatments that aren’t covered, and discouraging too many people from getting
colonoscopies, pap smears, and breast
exams that could save lives.
Most people believe the
Affordable Care Act (ie. Obamacare) made preventive care 100% free. But the
reality is more complex.
We’ll sort it all out in this article.
Scenario 1: “Shouldn’t this visit be free?”
A mother shows up to her
family doctor’s office for her daughter’s 9 month-old well-child check.
Although she thinks the visit should be free, the front desk requests a $25
co-pay before they can see the doctor. Instead of arguing, she slaps down her
credit card and decides to ask the doctor about the charge. But her doctor
doesn’t know anything about the co-pay or that it should be free, and she’s
back to square-one.
Reality Check:
This scenario actually
happened to several UHPP staffers. Although these example are common,
the solutions are also clear-cut. The Affordable Care Act (ACA) mandates that a list of
preventative care services are free for adults,
women,
and children.
This rule applies to both insurance purchased on the private market, and policies
offered by employers. This list of free preventive care includes well-child
checks and immunizations, and applies all levels of plans (Bronze, Silver,
Gold, and Platinum), as well as high-deductible and health saving account
plans. All of these services are offered without charging a copayment or coinsurance as
long as you stay within network, even if haven’t met your yearly deductible.
But there are a few catches.
First, “grandfathered”
private insurance plans exempt from offering preventive care at no cost. Both
private market and employer-sponsored health plans can be grandfathered. To be
a grandfathered plan, the consumer must have been enrolled in the plan before
March 23, 2010, and the plan has not changed much since then. Tens of thousands
of Utahns have avoided signing up for ACA-quality insurance to maintain their
grandfathered plans. But this means they could be paying for preventative care
(as well as pre-existing conditions) that are free in ACA plans.
Do you have a grandfathered
plan? Check your plan’s materials or ask your employer or benefits
administrator. Or review this checklist here.
Second, some medical
providers have decided to collect co-pays for preventive care in case the visit
is upgraded to a therapeutic visit. This can happen when a provider runs
additional tests or performs a minor surgical procedure that is not considered
preventive care. Your doctor might—or
might not—tell you that this extra step could result in additional charges.
However, if you are charged a co-pay and the visit turns out to be 100%
preventive care, you are entitled to a refund. But many provider offices aren’t
making it easy to reclaim these co-pays (a UHPP staffer eventually got $90 in
co-pays reimbursed after several inquiries to the clinic's business manager).
Third, patients can’t expect
to schedule a preventive care visit and show up with a laundry list of ailments
and extra tests they want done. That’s like going to a dealership to test-drive
a new car and deciding to run a bunch of errands. To be considered free preventive care, the
test or screening must receive an “A” or “B” rating from the U.S. Preventive
Services Task Force and be included on this list.
Scenario 2: “I owe how much?”
A patient sees a doctor for a
routine colonoscopy (Note: Most people over age 50 should get a colonoscopy to
screen for colorectal
cancer, which kills 50,000 people a
year). Since a colonoscopy is preventive care, the patient isn’t charged for
the procedure. However, if a doctor removes a polyp during the procedure (while
the patient is sedated), the visit gets upgraded from preventive care to a therapeutic treatment. As a result, the patient could wake up to hundred
dollars of charges due to co-pays and cost-sharing.
Reality Check:
Colonoscopies detect polyps
in 25% of men
and 15% of women, making this scenario common
for patients with Medicare. Thanks to
the Affordable Care Act, patients with private insurance (including employer-sponsored
insurance and any private insurance purchased through healthcare.gov) should
not be charged cost sharing
for a screening colonoscopy that becomes therapeutic. That’s because the Obama
administration ruled that polyp removal is “an integral part of a colonoscopy”
and preventive care. However, this rule
only applies to procedures that are registered as preventive in nature, and
performed within network. And some insurance companies are still wrongly
charging co-pays for polyp removals, so consumers need to be vigilant against
extra charges (link; pdf). But
Medicare patients don’t have any protection from these charges (link). As a result, Medicare patients are charged a
copay, plus 20% of the doctor’s fee for polyp removal that is part of a
colonoscopy. A bill introduced in Congress would fix this Medicare
loophole, but it hasn’t passed yet.
In addition,
Medicaid coverage for preventative care is a state-by-state patchwork, with some states providing free
screenings and treatments, and others requiring co-pays and cost-sharing.
However, adult populations newly-covered by Medicaid expansion should receive
the same free access to preventive
care as
individual purchasing private insurance.
Wrapping it all Up
The primary lesson from these
two examples is that consumers need to be pro-active in educating themselves, their
friends, and their providers about how to access free preventive care. One
strategy is to print out this explanation and list of free preventive care services and bring it to your next appointment. A secondary lesson is that consumers need to
remember that free preventive care is a not a blank check to get all your
ailments fixed in one visit.
FAQ about ACA and Free Preventive Care
1) Which screenings, tests, and visits are
considered free preventive care?
U.S. Preventive Services Task
Force “A” and “B” List: http://www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm
Healthcare.gov list for
adults, women, and children:
2) Which insurance plans provide free
preventive care?
The mandate of preventive
care at no cost to the consumer applies to all private insurance—both
employed-sponsored and purchased on the private market—that dates from after
March 23, 2010. This includes all new insurance policies purchased on
healthcare.gov or the private market and starting January 1, 2014 or afterwards.
This also includes most employer-sponsored plans (see question about
“grandfathered” plans below.
3) Do grandfathered insurance plans have to
cover preventive care for free?
No. Grandfathered insurance plans
can avoid offering preventive care at no cost. To be a grandfathered plan, the
consumer must have been enrolled in the plan before March 23, 2010, and the
plan has not changed much (see details below) since then. Both
employer-sponsored and private market insurance plans can be grandfathered.
Grandfathered plans DON'T
have to:
-Cover preventive care for free
-Guarantee your right to appeal
Protect your choice of doctors and access to emergency care
-Be held
accountable through Rate Review for excessive premium increases
4) How do you know if your plan is
grandfathered?
Check your plan’s materials
or ask your employer or benefits administrator to find out if your health plan
is grandfathered. To be a grandfathered plan, the consumer must have been
enrolled in the plan before March 23, 2010 and the plan has not changed much
since then. In Utah, insurers were allowed to grandfathered their plans into
2014, and now into 2015 and perhaps 2016. However, it’s more likely that small
group plans will get long-term grandfathering than individual private insurance
policies.
5) How does an insurance plan get to remain a
grandfathered plan?
To maintain grandfathered
status, a plan must look at its benefits and contribution levels as of March
23, 2010 and must not:
• Eliminate or substantially
eliminate benefits for a particular condition.
• Increase cost-sharing
percentages.
• Increase co-pays by more
than $5 or a percentage equal to medical inflation (currently 9.5 percent) plus
15 percent, whichever is greater.
• Raise fixed amount
cost-sharing other than co-pays by more than medical inflation (currently 9.5
percent) plus 15 percent.
• Lower the employer
contribution rate by more than 5 percent for any group of covered persons.
• Add or reduce an annual
limit.
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