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!

 

Browsing the Health Insurance Exchange

Since Open Enrollment for health insurance began this past Tuesday, all major news outlets have been reporting on the glitches and capacity overload that have prevented users from getting into the sites (see yesterday’s health care news).

When things do settle down and you are actually able to get in, what will you find?

If the consumer experience is anything like what brokers went through to register with the exchanges during the summer months, you can expect to be asked numerous, very specific, identity-verifying questions — along with your name and social security number — in order to establish an account.  Questions like: “on what street did you live in 1982?”  “with what bank did you refinance your home in 2004?” “what was your phone number in 1966?”

Of course, these questions are asked for the purpose of verifying that you truly are who you say you are.  And that is a good thing in light of the prevalence of identity theft.

But, a word of advice:   As a casual user, you will NOT be able to browse plans before establishing an account.  And, establishing an account will not be as simple as choosing a user name and password.  So, be prepared to jump through some hurdles and answer some very detailed — and often obscure — questions about yourself.

We invite you to visit our website www.vamedicalplans.com.   As carriers make their 2014 plan and rate information available, you can find it here, directly on our site.   You can browse available plans with just a few key strokes — and no obligation.

And when your browsing returns 10-15 options, leaving you unsure of the best one, give us a call or send us an email.  We’ll be glad to help!

Enrolling in Health Insurance Under Obamacare

October 1 is here,  and the exchanges have officially opened.

As we expected, the opening of the exchanges came with technical glitches and system delays.  Both the Virginia and Maryland exchanges, like many across the country, had crashed by 9:00 am.

But, things will settle down, and you will be able to purchase health insurance for next year.  Remember, you have until December 15, 2013 to enroll in a plan effective January 1, 2014.

Despite what you may hear about buying health insurance being as simple as purchasing a plane ticket on a site like Expedia, our experience shows us this is not the case.  Technical glitches aside, the application process is complex, and the choices you will be presented with will likely be difficult to decipher.

Please contact us for help.  We are authorized to enroll people through the exchanges in Virginia, Maryland, and the District of Columbia.  We can also assist with off-exchange plans.  Best of all, it costs you no more for our services!!

Here are three ways you can get started:

1. Visit our website:  www.vamedicalplans.com  (click on “Get Quotes”)
2. Send us an email: jkatz@vamedicalplans.com
3. Give us a call: 1-800-867-0800

Please be patient as we work hard to respond to each and every inquiry.  As you can imagine, we are experiencing a high volume traffic at this time!

In the meantime, click here for our 7 easy steps to prepare for enrollment.

Health Insurance Premiums Under Affordable Care Act

How will health insurance premiums be calculated in 2014, under Affordable Care Act (ACA)?

A policy’s premium is the monthly fee paid to the insurance carrier for health insurance coverage.

In pre-ACA policies, insurance carriers can charge differing premiums based upon many factors including, most notably, a person’s age and current health status.  Today, the premium paid by someone with a medical condition is typically much higher than that of someone with no known medical problems.

Under ACA, starting January 1, 2014, premiums can vary based only on the following:

• age (note: insurers can charge an older person no more than three times what they would charge a younger person for the same policy)
• where a person lives
• whether or not a person smokes

In addition, under ACA,

• coverage cannot be denied for pre-existing medical conditions
• coverage cannot be priced higher for someone who is overweight
• coverage cannot be priced higher for someone in poor health

It is important to note that this discussion is only about PREMIUMS, not total cost of health care.  Typically, you can get a lower monthly premium by increasing the amount you will pay for your care at the time you visit the doctor, emergency room, hospital, clinic, or other medical provider.  This is known as cost-sharing and comes in the form of deductibles, co-pays, and co-insurance.

Under ACA, the degree of cost-sharing for a particular policy determines its “level”.  Plans will be classified into four standard levels:  bronze, silver, gold, and platinum.  Plans in the gold and platinum tiers will have lower deductibles — and higher premiums — than those in the bronze and silver tiers.

As you can imagine, then, looking only at the monthly premium when choosing a health insurance policy is probably not a good idea!  Be sure you fully understand the provisions of the coverage so you can decide the right balance for you, given your particular situation.

In addition, depending on your income level and household size, buying health insurance on your state’s exchange may entitle you to a subsidy, which could lower your premium considerably.

Let us know, by phone or email, if we can be of assistance to you as you select your coverage for 2014 — on or off the exchange, with or without a subsidy.