Next Year, Will Your Employer’s Insurance Cover 62 Services and Products with No Co-Pay or Deductible? How Much Will You Save? Maggie Mahar Health Beat Blog
Under the ACA, some 62 preventive services and products will be free (in the past much of the preventative medicine was charged to patient on a non-negotiated rate. Today, they are financed through regulations applied to the insurance industry): no copays and the deductible will not apply. The list includes vision checks for children, birth control, and more than a dozen vaccines.
This rule will hold true not just for plans sold in the exchanges, but for most employer-sponsored plans. Under Obamacare, they, too, must offer preventive care without cost-sharing – unless they are “grandfathered.” (Grandfathered plans are policies that existed before the ACA was passed in 2010, and that have not made substantial changes to benefits or cost-sharing since then.)
The ACA’s list of preventive services and products covers most of the reasons that many of us visit a physician – for blood pressure checks, cholesterol checks, flu shots, mammograms, tetanus shots, Pap smears or colorectal cancer screening.
Some of us go to the doctor because we want help losing weight, or quitting smoking. Counseling and smoking cessation products – including nicotine patches – all make the list.
If we feel sad, and don’t know why, we may want to be screened for depression. Under Obamacare, this is a free preventive service. If you are a new mother who is feeling blue – or a 60-year-old man who just doesn’t want to get up in the morning – and your primary care physician (PCP) determines that you are depressed, he will send you to a someone who can provide counseling and or medication. The initial consultation with your PCP is free.
Preventive care for kids
As parents, we take our children to doctors for a host of reasons – often because we want advice. “What should I feed a plump six-year old?” “My 14-year-old does not like to leave his room-and he is being teased at school. Should I be worried?”
The ACA lists 25 preventive services for children, including diet counseling, depression screening for adolescents, , oral health risk assessments for children under age 11, behavioral and developmental assessments, vaccines to protect against 12 diseases, obesity screening and counseling, flu shots and tetanus shots.
How Much Will You Save? Why Should Men Pay for Contraception?
A woman who uses birth control may save up to $600 a year.
Some men are not happy that part of their insurance premium will pay for contraception. “I’m single and I never plan to have children” one HealthBeat reader grouses. “Why should I pay for it?
There are many answers. But here is an easy one: Women use more preventive services when they are younger, but as men age, the fact that they didn’t go to the doctor for blood pressure screening – or help losing weight – catches up with them. According to the Health Cost Institute, healthcare spending for women exceeds spending for men until age 60. At that point men’s healthcare becomes more costly.
This is when healthy women begin subsidizing men. Of course, much depends on how long an individual lives. If a fit 70-year-old woman survives until she is 95, she may, in the end, cost society more than an overweight man who has a knee replacement, suffers from diabetes, and dies of heart disease at age 75.
But over the long run, these things even out. Different people need more care at different points in their lives. This is how insurance works: over time, we subsidize each other.
Most won’t exceed their deductibles
Lately, Obamacare’s opponents have been fueling fears that under reform, we will have to pay thousands of dollars out of pocket before our insurer begins paying medical bills.
Last week, an ABC television station in Phoneix warned viewers that if they purchase a relatively low-cost Bronze plan in an Obamacare exchange, they may be in for a rude awakening when they try to use the policy and discover that they “may have to spend $5,000 or more” paying down their deductible, “before the insurance kicks in.”
The notion that many of us will have to pay $5,000 or $6,000 out of pocket is yet another free-floating Obamacare myth. $6,350 is the maximum that an insurer can ask you to pay in co-pays and deductibles, and most people will never approach that cap, in part because so many services are considered “preventive.”
Under reform the only people who will reach the maximum are those who suffer from a serious chronic illness, or who land in a hospital.
How much will you save?
In 2011, primary care docs charged an average of $119 for a preventive care visit while specialists billed $128. Patients who had no insurance were expected to pay the full amount. Those who bought their own insurance in the individual market often found that unless they had met their deductible, they, too, had to pay 100 percent of the bill.
Even families who have employer-sponsored benefits might be asked for a co-pay of $15 to $40 per visit – or perhaps 20 percent of the bill. For a family with children, those $25-to-$40 co-pays can add up.
According to the Census Bureau, the average American visits a doctor 3.9 times a year. Let’s assume that two of those appointments are for preventive care. At $25 per visit, a family of four might save $200 a year because they no longer have to shell out co-pays. A woman of child-bearing age could save up to $600 annually because under the ACA her birth control is free.
Preventive care for women
Obamacare lists some 22 preventive services for women. Pregnant women can receive free screening for anemia urinary tract infections, gestational diabetes and hepatitis B. Later, they are eligible for breastfeeding counseling and breast pumps.
The ACA pays for breast cancer genetic test counseling for high-risk women, domestic and interpersonal violence screening and counseling, and osteoporosis screening for at-risk women over 60. Then there are Pap smears, mammograms, and, the most controversial preventive product – contraception.
Some men grumble: why should we have to bankroll so many services for women?
There are many answers, but here is one of the simplest: Women use more preventive services when they are younger, but as men age, the fact that they didn’t go to the doctor for blood pressure screening – or help losing weight – catches up with them. According to the Health Cost Institute, healthcare spending for women exceeds spending for men until age 60. At that point, men’s healthcare becomes more costly.
This is when healthy women begin subsidizing men. Of course, much depends on how long an individual lives. If a fit 70-year-old woman survives until she is 95, she may, in the end, cost society more than an overweight man who has a knee replacement, suffers from diabetes, and dies of heart disease at age 75.
But over the long run, these things even out. Different people need more care at different points in their lives. This is how insurance works: over time, we subsidize each other.
Maggie Mahar Health Beat Blog and Health Insurance Org “62 Other Reasons To Say Ahhhh”
Free?
No, just paid for indirectly by someone.
STR:
Nonsense, financed by many of the regs. put in place to squeeze the excess profits out of the industry in which you work. Please come up with something better as this does not become you.
And what is wrong with cycling excess (your word!) profits back to society?
“Excess profits.” Definition please. Much of the “funding” is coming from the working middle class caught in increased co-pays and deductibles.
On another matter, with the unprecedented number of new and changed insurance policies, family practice offices will likely have major problems with registration and billing, and the whole revenue cycle could grind nearly to a halt. Should be very helpful to primary care operations.
One day Rusty will actually come up with real numbers instead of “Much of the “funding”…
but not today.
Course we will ignore that the topic is how much people will have to pay out of pocket , so in essence it is free, though doubtlessly paid for by premiums.
Just like before the ACA.
” family practice offices will likely have major problems with registration and billing, and the whole revenue cycle could grind nearly to a halt.”
Why?
Are you telling me that family practices are not capable of accessing an insurance companies billing system?
That the “unprecedented”policy changes(which of course you have defined no basis) will totally change the way a family practice charges insurance companies?
That insurance companies will all change all of their systems as opposed to just changing the compensation which they have done on a constant basis?
For that matter, that family practices do so many totally different procedures on a constant basis that they will have trouble filling out a form for those procedures?
Sorry, I have a hard time understanding why a family practice would struggle accessing a system and putting in the same codes they did last year, regardless of what the insurance company pays for that procedure, not to mention why a family practice would sign up with an insurance company without knowing their compensation.
Course, insurance companies and providers have been doing this for decades and decades, but somehow the system is in danger of “grinding to a halt”.
It is nebulous; however, the $ saved is the result of these services added as coverage without copay or deductible. While not detailing a specific figure, it is a cost save for the insured whether they have a high deductible or a large co-pay.
Preventive health services for adults
Most health plans must cover a set of preventive services like shots and screening tests at no cost to you. This includes Marketplace private insurance plans.
Preventive care benefits
Preventive care helps you stay healthy. A doctor isn’t someone to see only when you’re sick. Doctors also provide services that help keep you healthy.
Free preventive services
All Marketplace plans and many other plans must cover the following list of preventive services without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible. This applies only when these services are delivered by a network provider.
1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
2. Alcohol Misuse screening and counseling
3. Aspirin use to prevent cardiovascular disease for men and women of certain ages
4. Blood Pressure screening for all adults
5. Cholesterol screening for adults of certain ages or at higher risk
6. Colorectal Cancer screening for adults over 50
7. Depression screening for adults
8. Diabetes (Type 2) screening for adults with high blood pressure
9. Diet counseling for adults at higher risk for chronic disease
10. HIV screening for everyone ages 15 to 65, and other ages at increased risk
11. Immunization vaccines for adults–doses, recommended ages, and recommended populations vary:
o Hepatitis A
o Hepatitis B
o Herpes Zoster
o Human Papillomavirus
o Influenza (Flu Shot)
o Measles, Mumps, Rubella
o Meningococcal
o Pneumococcal
o Tetanus, Diphtheria, Pertussis
o Varicella
12. Obesity screening and counseling for all adults
13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
14. Syphilis screening for all adults at higher risk
15. Tobacco Use screening for all adults and cessation interventions for tobacco users
Preventive health services for women
Most health plans must cover additional preventive health services for women, ensuring a comprehensive set of preventive services like breast cancer screenings to meet women’s unique health care needs.
Comprehensive coverage for women’s preventive care
All Marketplace health plans and many other plans must cover the following list of preventive services for women without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible.
This applies only when these services are delivered by an in-network provider.
1. Anemia screening on a routine basis for pregnant women
2. Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer
3. Breast Cancer Mammography screenings every 1 to 2 years for women over 40
4. Breast Cancer Chemoprevention counseling for women at higher risk
5. Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
6. Cervical Cancer screening for sexually active women
7. Chlamydia Infection screening for younger women and other women at higher risk
8. Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
9. Domestic and interpersonal violence screening and counseling for all women
10. Folic Acid supplements for women who may become pregnant
11. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
12. Gonorrhea screening for all women at higher risk
13. Hepatitis B screening for pregnant women at their first prenatal visit
14. HIV screening and counseling for sexually active women
15. Human Papillomavirus (HPV) DNA Test every 3 years for women with normal cytology results who are 30 or older
16. Osteoporosis screening for women over age 60 depending on risk factors
17. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
18. Sexually Transmitted Infections counseling for sexually active women
19. Syphilis screening for all pregnant women or other women at increased risk
20. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
21. Urinary tract or other infection screening for pregnant women
22. Well-woman visits to get recommended services for women under 65
Preventive health services for children
Most health plans must cover a set of preventive health services for children at no cost when delivered by an in-network provider. This includes Marketplace and Medicaid coverage.
Coverage for children’s preventive health services
All Marketplace health plans and many other plans must cover the following list of preventive services for children without charging you a copayment or coinsurance. This is true even if you haven’t met your yearly deductible.
1. Autism screening for children at 18 and 24 months
2. Behavioral assessments for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
3. Blood Pressure screening for children at the following ages: 0 to 11 months, 1 to 4 years , 5 to 10 years, 11 to 14 years, 15 to 17 years.
4. Cervical Dysplasia screening for sexually active females
5. Depression screening for adolescents
6. Developmental screening for children under age 3
7. Dyslipidemia screening for children at higher risk of lipid disorders at the following ages: 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
8. Fluoride Chemoprevention supplements for children without fluoride in their water source
9. Gonorrhea preventive medication for the eyes of all newborns
10. Hearing screening for all newborns
11. Height, Weight and Body Mass Index measurements for children at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
12. Hematocrit or Hemoglobin screening for children
13. Hemoglobinopathies or sickle cell screening for newborns
14. HIV screening for adolescents at higher risk
15. **Hypothyroidism screening for newborns
16. Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary:
o Diphtheria, Tetanus, Pertussis
o Haemophilus influenzae type b
o Hepatitis A
o Hepatitis B
o Human Papillomavirus
o Inactivated Poliovirus
o Influenza (Flu Shot)
o Measles, Mumps, Rubella
o Meningococcal
o Pneumococcal
o Rotavirus
o Varicella
17. Iron supplements for children ages 6 to 12 months at risk for anemia
18. Lead screening for children at risk of exposure
19. Medical History for all children throughout development at the following ages: 0 to 11 months, 1 to 4 years , 5 to 10 years , 11 to 14 years , 15 to 17 years.
20. Obesity screening and counseling
21. Oral Health risk assessment for young children Ages: 0 to 11 months, 1 to 4 years, 5 to 10 years.
22. Phenylketonuria (PKU) screening for this genetic disorder in newborns
23. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
24. Tuberculin testing for children at higher risk of tuberculosis at the following ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years.
25. Vision screening for all children.