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Health Insurance & Affordable Care Act

Consumers Expecting Free 'Preventive' Care Sometimes Surprised By Charges

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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."

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communications organization not affiliated with Kaiser Permanente.

Fri, Jan 17 2014

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