Senior Living Know your rights to get free screenings – InsuranceNewsNet

An ounce of prevention… well, you know the rest.

In medicine, prevention aims to detect problems before they become serious, affecting both a patient’s health and finances.

One of the most popular parts of the Affordable Care Act, which allows patients to get certain tests or treatments without paying money to cover copayments or deductibles, is based on this idea.

“There are still gaps to be filled,” said Katie Keithresearcher at the Center for Health Insurance Reforms in Georgetown University. 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, from an ongoing court case to Texas who could reverse it, 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 charges.

Here are five more things to know:

Insurance questions

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. 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.

Not all preventative services are covered

The federal government currently lists 22 broad categories of coverage for adults, another 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 Task Force on Preventive Servicesa non-governmental advisory group that assesses the potential benefits and harms of screening tests when used in the general population.

The task force, for example, recently recommended lowering the age for colon cancer screenings to include people between the ages of 45 and 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 area is also one in which Medicare sets its own rules that may differ from the task force recommendations, said Anna Howardhealthcare access specialist 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.

The task force, for example, 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.

Possible limits

Insurers have leeway over what is allowed by the rules, but they have also been warned that they cannot be parsimonious.

Californiafor example, recently 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 the parameters. Federal guidelines say that smoking cessation programs, for example, must include coverage for medications, 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. Insurers might choose to focus on generics, for example, rather than branded products. (The law also allows employers to opt out of the birth control mandate.)

Expect challenges

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 in effect for Medicare.

More recently, federal guidelines clarified that patients cannot be billed for colonoscopies ordered as a result of suspicious results 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. Marc Fendrickdirector of the University of Michigan Value Based Insurance Design Center.

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 is considered a diagnosis or a screening test are a problem for other types of tests, including mammograms.

This has recently been triggered Laura Brewer of Grass Valley, 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 didn’t cost her anything, so she was stunned by her bill for more than $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 out 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,” she said, “that’s often coded as a diagnosis.”

Vaccines, drugs

Dozens of vaccines for children and adults, including those against chicken pox, 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 medications to prevent HIV, as well as much of the associated testing and follow-up care, are also covered free of charge for high-risk HIV-negative adults.

And after?

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.

Among them are conservatives opposed to some of the free services, who have taken legal action in a Texas federal district court that, if successful, could override or restrict part of the law providing for free shared preventive care.

A decision in this case, Kelley v. Becerra — the latest in a series of ACA challenges since it took effect — could come 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.”

Kaiser Health News is one of three major operating programs established to help the public make informed decisions at Kaiser Family Foundation.

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