ACA rules on women’s coverage create confusion in practices

Preventive services can now be covered under health system reform, but when that kicks in depends on the patient’s plan.

By — Posted Aug. 27, 2012

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In addition to the varying coverage rules, co-pay amounts, deductibles and preauthorization requirements that each payer brings, physicians and their staffs are dealing with a new wrinkle — this one around preventive care for women.

As of Aug. 1, new and renewing plans were required by the Affordable Care Act to cover many women’s preventive services without any out-of-pocket costs to patients. The covered services include mammography, birth control and well-woman exams. Officially grandfathered plans, which existed as of March 23, 2010, and have not undergone significant change since then, are exempt from the requirement. For patients whose “plan year” started before Aug. 1, co-pays and deductibles still apply until the new plan year starts. There are other exceptions, such as the rule only applies to preventive care provided inside the plan’s network.

Adding to the confusion, some plans voluntarily adopted the new rule early. Other preventive services for men, women and children, including cancer screenings, vaccines and counseling about chronic disease were subject to the same rule effective Sept. 23, 2010.

The combination of all of those factors has made it very difficult for physicians and their staffs to know whether a given female patient should be paying anything out of pocket for her preventive care.

For some practices, it has been easier to stop charging co-pays for preventive services. That was the case for Women’s Health Associates, an ob-gyn practice in the suburbs of Kansas City, Kan., said practice administrator Sylvia Haverty. The practice, which has six doctors, stopped charging co-pays for preventive services this year because it was more practical than trying to check on every patient’s coverage, she said.

Ob-Gyn Associates in Reno, Nev., a 12-physician practice, made the same decision, said practice administrator Jeff Snyder. There are many large, self-insured employers in Reno whose plans are grandfathered and don’t have to follow the rule, but it was more efficient to stop collecting co-pays for preventive visits than to check on every patient’s coverage or charge a co-pay every time and end up issuing refunds, Snyder said. He cited a rule of thumb that issuing a refund costs about $8, so sending dozens of refunds could prove costly.

Both Haverty and Snyder said their practices have been billing patients when it turns out a co-pay or patient portion is in fact due.

Barbara Levy, MD, vice present for health policy at the American Congress of Obstetricians and Gynecologists, said she would expect many practices to stop collecting co-pays then bill when necessary.

“It’s really a pain to have to refund them,” she said.

Cindy Dunn, RN, vice president for professional services at Trellis Healthcare in Littleton, Colo., and an independent consultant for the Medical Group Management Assn., recommended that physicians and staff meet and review how preventive care visits are coded and billed. That way, doctors, front desk personnel and billing staff understand what has changed and how to deal with those visits, and might be able to collect up-front as they did before.

Dunn said she recommends that physicians and staff identify the practice’s top five payers then determine those payers’ policies, because their members will account for about 80% of patient visits.

“You need to research and know,” she said. “You shouldn’t guess.”

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What women’s preventive care insurers must cover

Under the Affordable Care Act that took effect Aug. 1, insurers are required to cover most preventive health care for women without requiring patients to pay anything out of pocket. There are some exceptions, including grandfathered plans, but in most cases patients will not owe anything out of pocket for these services:

  • Breastfeeding support, supplies and counseling
  • Contraceptives
  • HPV testing
  • Mammographies
  • Screening and counseling for domestic violence
  • Screening for gestational diabetes
  • STD counseling and screening
  • Well-woman visits

Source: U.S. Dept. of Health and Human Services, Health Resources and Services Administration (link)

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External links

U.S. Dept. of Health and Human Services, Health Resources and Services Administration, required health plan coverage guidelines on women’s preventive services (link)

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