Initially, when I sat down to write about coverage regarding Preventative Care Benefits vs. Diagnostic Care Benefits, I thought my research would focus on the many missed opportunities we all have when it comes to our Preventative Care Benefits. I quickly realized that the conversation, for a high percentage of the time, goes to the area of coverage for that dreaded test - the colonoscopy. The confusion over Preventative vs. Diagnostic in this particular area is without a doubt, dominant.
All and everyone covered by health insurance (there are few limitations), whether it is private or through the ACA (Affordable Care Act) have the opportunity to keep healthy by accessing certain testing without cost. These tests are known as Preventative Care Benefits and defined by Healthcare.gov at https://www.healthcare.gov/coverage/preventive-care-benefits/ as:
Routine health care, including screenings, check-ups, and patient counseling to prevent or discover illness, disease, or other health problems.
In March 2010, under the Patient Protection and Affordable Care Act, broad changes were made to standardize the billing, costs, and testing for certain health initiatives. Under this change (along with subsequent changes) coverage was standardized for tests deemed helpful in keeping the population healthy. The list is long, with specific areas dedicated to different segments of the population. Here are a few of note:
Preventative Care Benefits for Adults
One-time Screening for Abdominal Aortic Aneurysm – for men of specified ages who have a history of smoking
Blood pressure screening
Cholesterol screening
Colorectal cancer screening
Depression screening
Diabetes screening
Hepatitis and HIV screening
Immunizations (the list is quite extensive)
Tuberculosis screening
Preventative Care Benefits - Specific to Women
Breast cancer genetic counseling (for women at higher risk)
Cervical cancer screening
Osteoporosis screening
Rh incompatibility screening
Urinary incontinence screening
Well-women visits
Expanded list of preventative testing for pregnancy
Preventative Care Benefits - Specific to Children
Autism screening
Behavioral assessments
Blood pressure screening
Depression screening
Development screening
Fluoride supplements and fluoride varnish
Hearing screening
BMI measurements
Immunization vaccines
Well-child visits
What this means is that to a high degree, every person, by law, is entitled to testing for conditions as listed above (for a full list go to https://www.healthcare.gov/coverage/preventive-care-benefits/ ) – at no cost.
Know What Your Insurance Covers Beforehand
Each year in the fall, we at HealthLink Advocates, remind everyone to print and keep handy their Summary of Benefits and Coverage (SBC). We recommend this be done annually, as coverage changes from year to year, even if one stays on the same plan. What doesn’t change, however, is the organization of information on the Summary of Benefits and Coverage that guides us to our benefits. The SBC will talk about deductibles, copays, coinsurance, etc. They also will mostly, just silently address “Preventative Care Benefits”.
In most cases, these benefits are cost-free to the insured. As long as one stays “In-Network”, all costs incurred in the screenings noted to be “preventative” are 100% covered. No deductible. No copay. No coinsurance.
There are different specifics for each category that one needs to be familiar with, but nevertheless, we all leave a lot on the table when we fail to take advantage of these medical screenings. The intent is to keep us healthy and identify health problems before they become chronic conditions. Preventative health screenings are designed to combat the most important health care conditions in an effort to facilitate early diagnosis and treatment – all known to improve quality of life and prevent premature death.
The Nitty Gritty You Need To Know
For the most part, as long as you stay In-Network and follow the parameters outlined on Healthcare.gov. you are entitled to these screenings at no cost to you. However, as mentioned earlier, you sometimes have to walk a fine line. Nowhere is this situation more evident, than in the benefit of a colonoscopy.
Why is that? The standard for a screening colonoscopy reads as:
Testing is performed on an asymptomatic person to identify the existence of colorectal cancer or polyps.
This reads simple, but news reports over and over, especially when it comes to a preventative screening colonoscopy, detail how often a person goes in for a colonoscopy thinking that they are coded with a preventative status – but come out with a diagnostic status. How does this happen? Most commonly it has to do with the discovery of a polyp. If a polyp or lesion is found during the screening procedure, the colonoscopy then becomes diagnostic and may be reported with a diagnostic billing code. When a polyp or lesion is found, the physician may perform a polypectomy or biopsy. Many facilities will maintain the original testing status as preventative. Others will convert it to diagnostic. Further, once a polyp (or other cautious condition) is found, you may forevermore be subjected to “diagnostic status”. It is important to read your bill and stand your ground!
For the most part, according to the American Cancer Society, The Department of Health and Human Services has declared that polyp removal is part of a screening colonoscopy – if you carry private insurance, the colonoscopy itself should in and of itself remain covered at 100%. However, any biopsy, etc., or extended procedure to remove any biopsy may be billed. Additionally, if you are a Medicare patient, the test is no longer a “screening” test and you will be charged the 20% coinsurance (but you will not have to pay the deductible).
Many people have now opted into “High Deductible” health plans. Be cautious here. If that is the route you have opted for, you could wake up from your test, only to wind up on the hook! If you have a $4,000.00 copay (common for High Deductible plans), that is one expensive reclassification!
This is a lot of information – all of it important. We at HealthLink Advocates, cannot stress to our patients enough how important it is to understand their health plan. How important their Summary of Benefits and Coverage is, and how important it is to ask all of the right questions before your appointments.
Be smart – if you find the Summary of Benefits and Coverage confusing, reach out to your insurance company (the Customer Service Number is right on the card) and find out what your options are. Take advantage of all that you are paying for – especially when it comes to free screening tests…..just be smart enough to know beforehand the differences between “Preventative Screening” and “Diagnostic Screening”. If you are still confused…call us here at HealthLink Advocates. We are always happy to help!