Some preventive care to have no out-of-pocket cost

By Ricardo Alonso-Zaldivar, Associated Press

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WASHINGTON — From counseling for kids who struggle with their weight to cancer screenings for their parents, preventive health care will soon be available at no out-of-pocket cost under consumer rules the Obama administration unveiled today.

That means no copays, deductibles or coinsurance for those covered by the new requirements.

Administration officials speaking on condition of anonymity ahead of an announcement by first lady Michelle Obama said 41 million Americans will benefit initially, with the number projected to rise to 88 million by 2013. Many large company plans, which usually offer solid preventive benefits, will be exempt from the requirements.

Better preventive coverage is one of the goals of President Barack Obama’s health care overhaul law, part of a shift to try to catch problems early, before high cholesterol leads to heart disease, for example.

Premiums will inch up by 1.5 percent on average, as the cost of preventive care is spread broadly across an entire pool of insured people.

For an individual, that can mean considerable out-of-pocket savings. For example, a 58-year-old woman at risk of heart disease could save at least $300 out of her own budget on recommended tests, ranging from diabetes and cholesterol screening to a mammogram and a flu shot.

Research has shown that people tend to skip recommended preventive care if cost is an issue, and even a modest copayment can make a difference. Cost-free prevention was one idea that received widespread support during the contentious health care debate last year in Congress.

“We know that the best way to keep our families healthy and cut health care costs is to keep people from getting sick in the first place,” Michelle Obama said in remarks prepared for the announcement.

The prevention requirements take effect for health plans renewing on or after Sept. 23, which means most beneficiaries will see them starting Jan. 1. Coincidentally, that’s also when Medicare recipients get access to most preventive services at no out-of-pocket cost — another change under the health care law.

Under rules to be issued today by the government, health insurance plans have to cover four sets of preventive services at no additional charge to their members.

These include:

— Screenings strongly recommended with a grade of “A” or “B” by the U.S. Preventive Services Task Force, an independent advisory panel. Among them are breast and colon cancer tests, screening of pregnant women for vitamin deficiencies, tests for diabetes, high cholesterol and high blood pressure, as well as counseling to help smokers quit.

— Routine vaccines from childhood immunizations to tetanus boosters for adults.

— Well-baby visits to a pediatrician, vision and hearing tests for kids, and counseling to help youngsters maintain a healthy weight. These and other services are recommended under guidelines developed by the government and the American Academy of Pediatrics.

— Women’s health screenings, also to include tests called for under guidelines that are still in development and not expected to be be announced until August 2011.

Many large employer plans will not be affected by the new requirements if they are considered “grandfathered” under the health overhaul law. Lawmakers created that exception so Obama could deliver on his promise that the law would not force wholesale changes in existing insurance plans. However, as employers make changes to their plans over time, many stand to lose the exemption, meaning they would have to comply with the law’s requirements.

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Q & A

Question: What does it mean that the services will be free?

Answer: New insurance plans will be prohibited from charging consumers a co-pay or deductible for services getting the top recommendation from the U.S. Preventive Services Task Force.

These plans will also have to cover immunizations recommended for children and adults by an advisory committee of the Centers for Disease Control and Prevention.

Insurers could still charge consumers for services delivered out of network and for treating conditions identified by screenings.

In some cases consumers could also be charged if a preventive service is not billed separately from another service, such as an office visit.

Q: Which services would be covered?

A: The benefits vary depending on consumers’ age, sex and whether they are at higher risk for a medical condition.

The services covered include: colorectal cancer screening for adults over 50; hepatitis B screening and tobacco counseling for pregnant women; depression screening for adults and adolescents; HIV screening for adults at high risk; and obesity screening and counseling for adults and children.

Children would qualify for more than two dozen services, including vaccinations for influenza, diphtheria and tetanus, and screenings for hearing and vision impairment and autism.

A list of many of the services covered, as well as background about the benefits is available at
www.healthcare.gov/law/about/provisions/services/index.html

Q: What about mammograms?

A: In a controversial move last year, the U.S. Preventive Services Task Force recommended that women between 40 and 50 do not need regular mammograms.

But lawmakers inserted a provision in the new law specifying that women older than 40 will still be able to get a mammogram screening every year or two at no cost.

The administration is also working with an outside panel of experts to develop a series of other preventive services for women that may be covered in the future.

Q: Will everyone qualify for this new benefit?

A: No. Only people in new insurance plans beginning after Sept. 23 or in existing plans that change substantially will be able to get the discounted preventive services.

The health-care law exempts so-called grandfathered plans offered by employers that have not substantially changed since the legislation was signed in March.

To maintain grandfathered status, employers cannot substantially raise co-pays, deductibles and other employee contributions or lower their contribution to their employees’ premiums by more than 5 percentage points.

Q: How much difference will this make?

A: That’s difficult to say. Many experts and consumer groups are hopeful it will ultimately have a huge impact.

Tens of millions of Americans still do not get basic screenings for diseases such as colorectal and cervical cancer. Numerous studies have suggested that early detection of diseases as well as interventions to address bad habits such as smoking and overeating can improve health and productivity.

But it is still unclear how many people will take advantage of the less expensive services, some of which, such as dietary counseling for obese Americans, may not be readily available in some parts of the country.

Q: Will the added benefits drive up premiums?

A: They could. The administration estimated that the new benefits may push up premiums by 1.5 percent on average.

But officials at the Department of Health and Human Services noted that any premium increases may be offset as millions of Americans no longer pay out-of-pocket co-pays and deductibles.