Q&A Health Care Reform: Preventive Care

We know health reform is big and confusing. Some parts of the law started in 2010. Other parts are rolling out over the next eight years. Texas physicians have carefully studied the law to help you understand what the changes mean to your health care.

Here are a few questions Texas patients have asked their doctors. There are many more. Please feel free to submit your questions to Me&MyDoctor.

Understanding “Grandfathered” Health Insurance Plans and Preventive Care Services

A. Starting in 2012, new individual and group health plans must cover preventive health services, such as immunizations, cancer screenings, and well-child and well-woman checkups, without charging the patient coinsurance, co-pay, or a deductible. However, some patients still must pay for these services. A blog reader wrote and asked us why her health plan did not cover the cost of her flu shot.

Q: Does the Preventive Health Benefit Requirement Apply to All Health Plans?

A. The preventive health requirement outlined in the health law applies to new individual and group health plans written on or after Sept. 23, 2010. Plans written before March 23, 2010, are considered “grandfathered” and are exempt from this requirement. As long as a plan retains its “grandfathered status,” then the plan can require a copay, deductible, or coinsurance for the preventive health services you receive.

Q: Can a Plan Lose Its Grandfather Status?

A. Yes. If a grandfathered plan makes changes to the benefits it offers you or requires a significantly increased deductible, copay, etc., it will lose its grandfather protection. Some plans are trying to keep their grandfathered status because the additional coverage would cause an increase in plan premium cost.

Q: What Preventive Services Are Required by All Other Plans (Not Grandfathered)?

A. The required preventive services for new health insurance plans include:

• All vaccinations recommended by the Center for Disease Control’s Advisory Committee on Immunization Practices;
• All preventive care and screening for women and children recommended in comprehensive guidelines supported by the Health Resources and Services Administration; and
• All services rated “A” or “B” by the United States Preventive Services Task Force, including:
• Screening for breast cancer, cervical cancer, chlamydia, colorectal cancer, depression, gonorrhea, hypertension, lipid disorders, obesity, osteoporosis, diabetes, aortic aneurysm, and more; and
• Screening, treatments and/or counseling for many other health risk factors including obesity, smoking, and alcohol abuse.

The guidelines specify when the services are covered based on factors such as the patient’s age and health risk factors.

Health plans have interpreted these requirements in different ways.  Some will require many of these services to be delivered together in one annual visit.  Other plans may pay for them separately.  Some plans will cover particular services only when they are delivered by certain physicians or in certain facilities.  

Q: How Can I Find Out If My Plan Must Cover Preventive Care Without Coinsurance, Copay, or Deductible?

A. You should request information directly from your health insurance plan to determine whether the plan is grandfathered or whether specific preventive care coverage will be allowed when provided by your physician in his or her office or other setting.