Preventive care coverage a mystery to many patients

Physicians can discuss what an insurer will pay for in full, but time constraints in the exam room pose challenges.

By — Posted March 18, 2013

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Three years into the Affordable Care Act’s declaration that private health plans pick up the full rate for many preventive services, three out of every 10 patients still aren’t sure about what their insurer will cover.

A nationwide survey of 1,000 patients conducted by TeleVox, a high-tech patient engagement communications company, showed that 30% didn’t feel knowledgeable about what their health insurance policies covered in terms of prevention. Among baby boomers, 26% said they were not as knowledgeable as they could be about what their health insurance covers for preventive care.

Beginning in September 2010, the ACA mandated that new policies from insurers, including Medicare and private plans, provide coverage with no deductibles or co-payments for certain, common preventive services. In August 2012, HHS announced eight additional screenings for women under that ACA rule. There are many preventive services, broken down by age group and gender, that insurers pay physicians to perform but for which the cost is not passed onto patients. These include many vaccines; diet, tobacco and alcohol counseling; mammographies; diabetes screenings; colonoscopies; Pap smears; and cholesterol screenings.

In March, HHS addressed the worry expressed by patients and their advocates that people were eschewing the free preventive care for fear they would have to pay for additional care arising from these services. Now, certain types of care also get first-dollar coverage from insurers if they are performed at a preventive visit. Most notable in those addition services is the removal of any polyps discovered during a routine colonoscopy, wiping out potentially thousands of dollars in patient out-of-pocket costs.

However, just getting patients to realize their preventive care doesn’t require any out-of-pocket cost has often been a struggle. A December 2012 study in Health Affairs found that 40% of surveyed members in a major California health insurance plan didn’t know they could get preventive care at little or no cost under the ACA. In summer 2011, HHS launched a “Share the News, Share the Health” multimedia promotion after it discovered that only one in six Medicare beneficiaries had taken advantage of no-cost preventive screenings. CMS says that rate is now 70%.

TeleVox did not ask patients why there were not sure what preventive services their insurer covers. Glen Stream, MD, a family physician in Spokane, Wash., and board chair of the American Academy of Family Physicians, said it could be that a lot of patients haven’t followed what changes the ACA has brought to their insurance, and that the general complexity of health plans might confuse them. While the ACA mandates no patient costs for many preventive services, not all are covered in this way.

Doctor information outreach

Physicians should consider talking to their patients about preventive care and the risk factors of not getting screenings, said Allison Hart, director of marketing communication for TeleVox and its consumer and health care professional research program.

But with all of their other responsibilities, physicians may not have time to discuss insurance coverage of preventive care with every patient, Dr. Stream said. “It’s challenging. Prevention and wellness are very important in primary care, but the fact is face-to-face time with patients is so precious.” Various studies note that physicians say they feel squeezed in their work day.

Dr. Stream suggests that physicians could disseminate information about what preventive screenings carry no patient payment, perhaps through their websites, or through pamphlets or flyers in the office.

Also, patients can be guided to online resources at, which lists preventive services covered under ACA.

When patients are reluctant to get recommended preventive services, doctors should discuss risk factors and the importance of the recommended tests, he said. Insurance companies and health organizations also are responsible for providing this type of information, he added. And patients should be on top of their own health and insurance. “I see it as a shared responsibility,” Dr. Stream said.

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External links

Medicare preventive services covered under the Affordable Care Act, (link)

Preventive services covered under the Affordable Care Act, (link)

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