Healthcare Reform Preventive List

New guidelines with Healthcare Reform now provide some preventive services to be paid by your carrier at 100%.  We have posted the general list from the healthcare.gov  website below.  With any health insurance carrier, services are only processed as preventive if coded as such by your doctor.

            Preventive care is usually precautionary.  An example would be if your doctor orders a colonoscopy because of your age and codes the claim as preventive, this would process under the preventive benefit.  But, if your doctor recommends a colonoscopy to investigate symptoms, and codes the claim as diagnostic, this would not be considered preventive.

Healthcare Reform Preventive List

New Women's Preventive Services

Recently it was announced that the Affordable Care Act has been expanded to include additional prevention coverage for women's health and well being. Under the act, originally signed into law in March 2010, it is required that health plans cover preventive services without cost share, such as copays or coinsurance, when going to an in network provider. Coverage included preventive services like mammograms, colonoscopies, and immunizations.

On August 1, 2011, the Affordable Care Act was expanded to include well-woman visits, screening for gestational daibetes, HPV testing, counseling for STIs, counseling and screening for HIV, contraceptive methods and counseling (except when group exclusions apply), breast feeding support/counseling and supplies, and screening and counseling for interpersonal and domestic violence. For an outline of the guidelines, check out the US Department of Health and Human Services site.

Please note that these guideline are effective August 1, 2011, but non-grandfathered plan and issuers are not required to provider coverage without cost sharing consistent with the guidelines of the act until the first plan year that begins on or after August 1, 2012. As always, it is beneficial to contact your member services line with your insurance carrier to verify what all is covered (and how it will pay!) under your benefit plan.

Top 5: Ways to Control the Cost of Healthcare #4

4. Ensure that your lab work is being completed by an in-network/participating lab

Just like in network providers, it is important to utilize in network (or participating) labs in order to receive the highest benefit from your medical coverage. Just like going to an out of network provider, using an out of network lab can result in higher costs, balance billing, and claims going towards a higher, out of network deductible.

For instance, let’s say that you have the following benefits and have already met your in network deductible for the year.

Covered Benefits	Network	Non-Network
Deductible (single/family)	$500/$1000	$1000/$2000
Out of Pocket Limit (single/family)	$3000/$6000	$6000/$12000
Preventive Care Services Services include but are not limited to: Routine exams, pelvic exams, pap testing, PSA tests, immunizations, annual diabetic, eye exam, vision and hearing screenings ·         Physician Home and Office Visits (PCP/SCP) ·         Other Outpatient services @ Hospital/Alternative care facility	$25/$50 20%	40% 40%

You go to your physician for your annual preventative visit. You have run a check on your insurance carrier’s website, and you confirm that your physician is in network. During your annual preventative exam, your physician runs some bloodwork and sends it off to their lab. Your physician’s bill processes through insurance, and since you have already met your in network deductible, you only owe a $25 copay.

However, your lab work was sent to an out of network lab. They bill $100. The contracted rate for these services is $50, and your insurance carrier applies this to your out of network deductible, which you have not yet met. Since the lab is not contracted, they are able to balance bill, and you are responsible for $100.

Had you requested that your physician send your lab work to an in network lab (which you can find a listing by doing an search on your insurance carrier’s site), then the lab work would have been adjusted to the contracted rate of $50, of which you would have only been responsible for 20% (or $10 – a difference of $100 for you).

For more ways to control your healthcare costs, check out our Top 5: Ways to Control the Cost of Healthcare and check back often for articles explaining further each of these examples.

Trends in Benefits: HPV Testing Not Covered as Preventive

Healthcare reform has brought on many changes to the healthcare industry, and one of the benefits that has brought about significant confusion has been the coverage of preventive services in full.

Recently, our team has begun to see a trend of charges for women going for their annual exam with their OB/GYN. Upon investigation, everything has been coded as preventive for many of these exams, but the charges are coming from the lab. Though most of the labs run are coded and can be run through benefits as preventive, HPV screenings are not on the approved list for preventive coverage and are therefore not covered in full. Thus, members are finding that their exams, which they believed would be covered in full, are having some charges. We have seen this happen with multiple carriers, especially as physcians are beginning to make this screening a part of their protocol for annual exams.

So long as this screening remains off of the list of codes that must be covered in full for preventive services and physicians continue to make this a part of their protocol, members will most likely continue to see this charge during their annual exam.

UPDATE: Please see our article on new women's preventative services

Understanding Preventive Care Coverage

One of the changes to Healthcare over the past year included the coverage of recommended preventive services without charging out of pocket costs through the Affordable Care Act. With this change, many Americans have gone to the doctor for covered screenings including eye chart vision screenings, mammograms, and colonoscopies. However, confusion arises if they receive a bill for these screenings.

It is important as significant changes are made to fully understand what specifically is covered by your health plan. For instance, you may want to be aware of the following regarding Preventive Care Covered Services: