Murky preventive care rules trouble insurers, patients

The Affordable Care Act requires most health plans to cover preventive services, such as cancer screenings, check-ups and contraceptives, without cost sharing. But some patients still face coverage exclusions--raising calls for more federal guidance, Kaiser Health News reported.

Healthcare reform provisions that eliminate most patient cost sharing for preventive services follow recommendations by the U.S. Preventive Services Task Force. However, preventive care coverage rules get a bit murky as new research changes the list of recommended preventive services, KHN noted.

In fact, earlier this month, HHS announced that based on a review of evidence, ACA expanded access to tamoxifen and raloxifene without copays or other out-of-pocket costs for women at high risk for breast cancer, FierceHealthPayer previously reported.

America's Health Insurance Plans cited a lack of specific federal guidance for preventive care coverage variations while advocates and policy experts highlighted the difficulty in translating clinical recommendations about preventive services into "insurancespeak." Translating that into an insurance claim is "much more complicated than just pointing to a list and saying 'that's covered,'" Karen Pollitz, a senior fellow at the Kaiser Family Foundation, told KHN.

For example, while health plans must cover "the full range of FDA-approved contraceptive methods, including, but not limited to, barrier methods, hormonal methods and implanted devices" at no cost to the patient, several plans exclude the contraceptive ring and patch because insurers claim they use the same hormones as the pills and therefore are the same method.

Procedure billing codes also cause problems with preventive care coverage rules, as the fee-for-service model assigns multiple codes for a procedure and all related services--for instance, one code for the colonoscopy and separate codes for the anesthesia and the facility, according to KHN.

Moreover, 30 million people will likely remain uninsured and miss out on preventive care that health plans are required to cover with no patient cost sharing. People who are exempt from the individual mandate, immigrants who are in the country illegally and low-income legal immigrants are among several groups who may fall through the preventive care coverage cracks, FierceHealthPayer previously reported.

For more:
- here's the KHN article

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