The ACA eliminated co-pays for preventive care. So why are some doctors still making us pay?
|A new post-enrollment series in Health Matters|
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.
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.
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.