The new health-care law encourages people to get the preventive services they need by requiring that most health plans cover cancer screenings, contraceptives and vaccines, among other things, without charging patients anything out of pocket. Some patients, however, are running up against coverage exceptions and extra costs when they try to get those services.
Advocates and policy experts agree that more federal guidance is needed to clarify the rules.
Rebecca Hyde of Woodstock, Conn., was angry when, after getting a colonoscopy to screen for cancer in December, she got a notice that her insurer was charging a hospital "facility fee" of $1,935 against her $6,000 deductible. Such fees are not uncommon for hospital-based care
But since colonoscopies are recommended starting at age 50, the 53-year-old had not expected to owe anything out of pocket.
"I thought it was the bait-and-switch: They tell you it's going to be preventive and then you get a really large bill," she says.
Hyde discussed the problem with hospital billing staff, who offered to resubmit the bill using a different procedure billing code. Hyde says she hopes the issue can be resolved without having to appeal to her health plan.
Hyde's experience is not unique, says Mona Shah, associate director of federal relations at the American Cancer Society Cancer Action Network. Other patients have reported being charged for services related to a colonoscopy, if not the actual screening itself. Last year, federal officials clarified that insurers can't impose cost sharing if a patient has a polyp removed during a screening colonoscopy, as Hyde did.
But the rules are murkier for other services. As in Hyde's case, it's often a problem with how a procedure is coded for billing purposes, Shah says. Instead of a single code that covers a procedure and everything related to it, the traditional fee-for-service system assigns multiple codes: one for the colonoscopy, for example, and others for the anesthesia and the facility.
"We're trying to get [the Department of Health and Human Services] to release guidance that says prevention should cover all related services," she says.
HHS spokeswoman Joanne Peters says the agency continues "to monitor how the preventive services provisions are being carried out, and we are working with stakeholders to ensure they understand our guidance and to offer further clarity to them when needed."
Lacking explicit federal guidance, "there may be some variation in coverage," says Susan Pisano, a spokesperson for America's Health Insurance Plans, a trade group. But "our plans are committed to doing what the [health law] says we should do."
Under the health law, preventive services are covered without patient cost sharing if they are recommended by the U.S. Preventive Services Task Force, an independent group of medical experts that evaluates scientific research and makes recommendations about clinical preventive services. Other preventive services are also covered without cost sharing, including recommended vaccines and services related to women's and children's health.
The provisions apply to all plans except those that are grandfathered under the law. (There are also limited exemptions from the requirement to provide birth-control coverage without patient cost sharing for some religious organizations. A number of other employers have challenged the requirement; the Supreme Court will hear two of these cases this spring.)
As new research becomes available, the list of recommended preventive services changes. This month, for example, HHS released guidance saying that women at increased risk of breast cancer could receive, without cost sharing, medications such as tamoxifen and raloxifene.
The system still has kinks to work out. Translating a set of clinical recommendations about preventive services into an insurance claim and describing how it should be paid is "much more complicated than just pointing to a list and saying 'that's covered,' " says Karen Pollitz, a senior fellow at the Kaiser Family Foundation (KHN is an editorially independent program of the foundation.)
"There isn’t an intermediary to translate this into insurancespeak," says Jeff Levi, executive director of the Trust for America’s Health, an advocacy group focused on disease prevention.
One of those areas of sticky coverage involves contraceptives. According to guidance from HHS, health plans must cover "the full range of FDA-approved contraceptive methods, including, but not limited to, barrier methods, hormonal methods, and implanted devices."
But according to a study by the Guttmacher Institute, a number of plans appear to be excluding the contraceptive ring and patch from coverage without cost sharing
"They're claiming that it's the same hormones as the pills, so it's the same method," says Adam Sonfield, a senior public policy associate at Guttmacher who authored the report.
"The pill, the ring and the patch are different types of hormonal methods," said an HHS official in an e-mail. "It is not permissible to cover only the pill, but not the ring or the patch."
The health law does permit plans to apply medical management techniques to "control costs and promote efficient delivery of care." So, for example, a plan may charge a co-pay for a brand-name contraceptive if a generic version of the same drug is available at no charge.
Implementing the preventive services provisions will require constant monitoring, "and not just through complaints," Pollitz says. "Because for every person who complains, there's a whole lot more who don't complain or don't even get the service."