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Health Insurance & Affordable Care Act

Consumers Expecting Free 'Preventive' Care Sometimes Surprised By Charges

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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."

Fri, Jan 17 2014

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