Preventive vs. Diagnostic Medical Services Under the Affordable Care Act

The Affordable Care Act (ACA) mandates that all qualified health insurance plans (except grandfathered plans purchased prior to March 23, 2010 and still in place) include coverage for ten essential health benefits.  That does not mean these medical services are necessarily free, merely that your health insurance will cover some or all of the cost.

But certain preventive services are free.  This means your health insurance must cover 100% of the service without charging you a co-payment or co-insurance, even if you have not yet met your deductible.

NOTE: you must use an in-network provider to receive free preventive care.

Preventive Services vs. Diagnostic Services

Many people are surprised to learn a service they believed to be preventive — and therefore free — was not considered preventive by the insurance company — and therefore resulted in a medical claim.

It is important to understand the difference between a preventive service and a diagnostic service.

Preventive services are things that prevent health problems.  Preventive care happens before you feel sick.  Examples are immunizations, lab tests, physical exams, certain medications.

Diagnostic services are things that help your doctor understand the symptoms you’re having and diagnose an illness. Diagnostic care happens when you feel sick or have a known health issue.

The tricky part is sometimes the same service may be preventive — and free — under certain circumstances, yet diagnostic — and not free — under others.

How Do I Know if the Care I Receive is Preventive or Diagnostic?

Whether a service is preventive or diagnostic depends on the reason for having it.

In general, a medical service is considered diagnostic if it is done for the purpose of monitoring, diagnosing, or treating a known health issue or symptom.  For example:

If you have a known, already-diagnosed chronic disease like diabetes, and your doctor monitors your condition with certain tests, these tests are considered diagnostic.

If a preventive screening test reveals a health problem and then your doctor orders more tests to further diagnose the exact issue, these tests are considered diagnostic.

If you are having symptoms, like abdominal pain, and your doctor orders tests to figure out the cause, these tests are diagnostic.

A service is considered preventive if it is done for screening purposes, and not based on any symptoms.  Certain preventive services, when done on a recommended schedule (e.g., at a certain age or frequency), are covered at 100%.

The Same Service can be Preventive or Diagnostic, Depending on the Reason

Here are a few examples of services that can be either preventive or diagnostic, depending on the reason for the service:

• Mammogram – preventive if done as a screening based on your age or family history; diagnostic if you have symptoms like pain or have detected a lump.
• Cholesterol testing – preventive if done as a screening based on your age or family history; diagnostic if you were already diagnosed with high cholesterol and your doctor is monitoring your numbers.
• Colonoscopy – preventive if done as a screening based on your age or family history; diagnostic if you have symptoms like bleeding or irregularity.
• Colon Polyp Removal – the removal itself is preventive if done as part of a screening colonoscopy; if sent to the lab for testing, this is diagnostic.

Understand Your Policy

It is best to fully understand the provisions of your health insurance policy when seeking medical care.  You can consult your plan’s documentation for specifics on your coverage.  If we helped you enroll in coverage, you can also give us a call and we’ll be glad to help!

 

Metal Plans Under the Affordable Care Act

The Affordable Care Act (ACA) created four new designs for health insurance policies. You may have heard policies referred to as “metal plans.”  This is because each design is named after a metal:

Bronze  |  Silver  |  Gold  |  Platinum

The four metal plans are distinguished from one another by their actuarial value.

Actuarial value (AV)  is the average amount of covered health care expenses that will be paid for by the insurance carrier.  It is also known as cost sharing.  The higher a plan’s AV, the greater the cost paid by the insurance company and the lower the out-of-pocket costs for the person covered.

Within the same insurance company, plans at the bronze level will have the lowest premiums, while plans at the platinum level will have the highest premiums.

However, it is possible, for example, for premiums charged by one company for its silver plan to be lower than the premiums charged by another company for its bronze plan.  That is why it is so important to fully understand the features of any plan you are considering.

Essential Health Benefits

All plans, regardless of their metal level, must cover ten essential health benefits.  Plans can offer additional benefits, but the basic, essential benefits must be covered.

Note, that’s not to say all of these benefits will be covered at 100%;  while certain preventive services must be covered at 100%, the portion of the expense paid by your policy for other essential services will depend upon the plan’s metal level as described above.

Here are the ten essential health benefits:

1. Ambulatory Patient Services — care you receive on a walk-in basis (e.g., doctor visits)
2. Emergency Services — care you receive at an Emergency Room
3. Hospitalization — medically necessary surgeries and other inpatient procedures
4. Maternity Care and Newborn Care
5. Mental Health Services and Substance Use Disorder Services — includes counseling and behavioral health treatment
6. Prescription Drug Coverage — prescription (but not over-the-counter) medications
7. Rehabilitative and Habilitative Services and Devices — examples are relearning to walk after a stroke (rehabilitative) or learning new skills like diabetes management (habilitative)
8. Lab Tests and Services — for example x-rays
9. Preventive and Wellness Services and Chronic Disease Management
10. Pediatric Medical Services (including both oral and vision care)

How Much Do the Metal Plans Cost?

Regardless of the metal level, health insurance premiums vary based upon:

• Your age
• Whether or not you smoke
• Where you live
• The number of people on your policy (e.g., family, individual, children, etc.)

Premiums cannot differ based on your health status or your gender.  In other words, you cannot be charged more if you have an existing medical problem, or based on your gender.

Since insurance carriers each set their own rates, it is always best to compare options available from more than one carrier.

All Health Insurance Premiums Include the Services of a Broker

That’s right.  It costs no more to use the services of a broker.  So, why not get the most for your premium dollars and let us help!   Virginia Medical Plans assists our clients in choosing the right coverage, enrolling in a plan, and handling administrative and claims issues for the life of their policy.

Call or email our office today!

• Phone:  1-800-867-0800
• Email: jkatz@vamedicalplans.com

More on Pediatric Dental Essential Health Benefit

We recently received a well-written brochure about the Pediatric Dental Essential Health Benefit (EHB) —  Click here.

Although the guide was produced by United Health Care (UHC) and we write dental and health insurance policies with many other carriers, it contains some really useful information about how the pediatric dental EHB will work in 2014 under the Affordable Care Act (ACA).

We have put up UHC’s guide under our Free Resources tab.  Feel free to use it to supplement the information we have posted here on our site as well.

We are available to answer any questions you may have.

Pediatric Dental Benefit in Virginia under Affordable Care Act

The Affordable Care Act (ACA) requires health insurance plans to cover ten essential health benefits (EHB).

One such EHB is pediatric dental care.

It sounds simple enough: “pediatric dental care” means providing oral health care for children.

But it turns out there are many questions — and few concrete answers — about exactly how the pediatric dental EHB will work in Virginia.  Here is some of what we do know:

States Decide How to Handle Pediatric Dental Coverage

States were given latitude in designing their requirements for pediatric dental coverage under the Affordable Care Act.  Therefore, each state is a little different, and some states are further along than others when it comes to laying out the details.

Pediatric Dental EHB in Virginia

What we know for Virginia is that the state’s pediatric dental benefit is required on all ACA-compliant individual and small group plans, regardless of whether or not you have children.  Coverage is modeled after the state’s Children’s Hospital Insurance Plan (CHIP) and includes:

• Access to oral health care for children up to the age of 19.
• Orthodontia benefit, but based on a strict definition of medical necessity.
• There will be no annual or lifetime benefit maximums.

“Access to oral health care” has not been clearly defined by all health carriers, and even some dental carriers are sketchy on the details of the types of services that will be covered.

Embedded, Bundled, or Stand-Alone

There are three ways to get coverage for pediatric dental care.  Coverage can be:

Embedded — pediatric dental coverage is included (embedded) in all ACA-compliant health plans, even if there are no children covered on your policy.  But, be aware that your dental benefit will probably only kick in after your medical deductible has been met, and there may be co-insurance or co-payments.

Bundled — coverage is provided by a dental carrier (possibly separate from your health carrier), but your medical and dental premiums are bundled so you make a single payment for both coverages.  You need to check carefully how deductibles work with bundled policies.

Stand-alone — a stand-alone dental insurance plan will have its own separate premium, separate deductibles, etc.  You might want to consider purchasing a stand-alone plan if the pediatric dental coverage embedded in your-ACA compliant plan does not meet your needs.

Deductibles, Co-Payments, Co-Insurance

Another area states have been given wide latitude is in setting deductibles, co-payments, and co-insurance. And we don’t know yet what these will be in Virginia plans.

Please keep in mind that a low-cost pediatric dental EHB embedded in your medical coverage may not cover a lot and could end up costing more than you expect once you actually go for dental care for your child!

Individual/Family Policies

	When Buying Coverage Off Exchange	When Buying Coverage On Exchange
If You Have Children Under age 19	Pediatric Dental Benefit must be included by law in any 2014 health insurance plan you buy. ACA-compliant plans will have pediatric dental EHB embedded, but be sure you understand what coverage you are getting for the additional premiums.  In particular, make sure you understand how your medical and dental deductibles work.  In some plans, dental coverage will kick in only after your medical deductible has been met. You are still free to purchase a stand-alone dental plan that meets the needs of your family.	According to the American Dental Association website, a federal interpretation of the ACA has determined that within the exchange the pediatric dental EHB need only be offered. Therefore, you do not need to purchase the pediatric dental EHB if buying an Exchange health insurance plan.   You may purchase a medical-only plan and then purchase a standard individual or family dental plan that meets your needs.  A stand-alone dental plan, however, is not eligible for a subsidy.
If You Do Not Have Children Under age 19	ACA-compliant plans will have embedded pediatric dental EHB, but it is of no use to you. Keep pediatric dental EHB premiums as low as possible by keeping benefits to the bare minimum. You have the option to purchase a stand-alone individual or family dental plan of your choosing to meet your dental care needs.	According to the American Dental Association website, a federal interpretation of the ACA has determined that within the exchange the pediatric dental EHB need only be offered. Therefore, you do not need to purchase the pediatric dental EHB if buying an Exchange health insurance plan.  Instead you may purchase a medical-only plan and then purchase a standard individual or family dental plan that meets your needs.  A stand-alone dental plan, however, is not eligible for a subsidy.

Small Groups (fewer than 50 full time employees)

If you are a small business purchasing insurance for your employees, some health insurance carriers are including embedded pediatric dental benefits with their medical plans.   Some will allow you to pull the embedded coverage out, and then purchase a stand-alone, exchange-certified dental policy for your employees that will satisfy the ACA requirement and better meet their needs.

Make sure you understand that with embedded pediatric dental EHB,  your employees will probably have to first meet their medical deductible before dental benefits kick in.

Anthem BC/BS has released detailed information on the Pediatric Dental Benefits that will be embedded in small group plans at a cost of about $6 per person, per month.  Click here.

Network of Dentists

ACA requires dental plans to offer an “adequate” selection of dentists, but things like how far a person should be expected to travel to see a dentist, or how long is reasonable to wait for an appointment, is up to each state to determine.

We do not have much information yet on how dentist networks are going to work in Virginia for the embedded pediatric dental benefit.

Questions Remain on Pediatric Dental Benefit

If you are confused, that is because this is quite confusing!

As of now the best we can see is that, for individuals, unless you are buying coverage on the federal exchange, you will have no choice but to purchase a plan with embedded pediatric dental coverage.  We are seeing approximately $6 per person, per month being charged for this.  It’s almost like a tax.  But you can still purchase a stand-alone (or bundled) dental plan that will meet your family’s needs.

As we learn more information, we will of course pass it along.  We do have a bit more information for how Maryland is handling the pediatric dental EHB, and will post that in an upcoming article.

In the meantime, give us a call if you have any questions.

Please be patient as we manage a high volume of calls and emails.