One goal of the Affordable Care Act was to boost the use of preventive health services by all Americans. The law attempts to do this by making those services – health screenings, vaccinations, well-baby visits, and dozens more – free to as many people as possible as soon as possible.
Now, new private health plans must offer the services without patient cost sharing.
Although that provision covers only a fraction of the population – existing plans were exempted – as of Jan. 1, all Medicare beneficiaries will be offered a host of new services with no out-of-pocket costs.
Dr. Meena Seshamani, the deputy director of the Office of Health Reform at Health and Human Services department, explains how her agency is implementing this provision of the ACA as well as how HHS hopes it will alter for the better the behavior of patients and physicians.
Rheumatology News: What preventive services will doctors be offering Medicare beneficiaries copayment-free in 2011?
Dr. Seshamani: Medicare beneficiaries with [fee-for-service] Medicare will receive free preventive care services and a free annual wellness visit, or physical. The complete list of preventive services is available in the Medicare & You Handbook, and it includes abdominal aortic aneurysm screening, bone mass measurement, certain colorectal cancer screening tests, immunizations for influenza and hepatitis B, and mammograms.
Most Medicare Advantage plans also are offering theses services without cost sharing, so beneficiaries should check with their plan.
RN: This change went into effect for private insurance plans created after health reform was enacted but not plans existing before then. Will long-existing plans, presumably covering most younger patients, ever have to fully cover preventive services under the law?
Dr. Seshamani: The ACA requires new insurance plans to cover an array of preventive services – those I mentioned above plus additional services including well-baby and well-child visits and routine immunizations – without charging a copay, coinsurance, or deductible. These rules do not apply to grandfathered plans, that is, plans that existed on March 23, 2010, and that have not made significant changes since then.
If a plan loses its “grandfather status” by making changes that reduce benefits or increase costs to consumers, it will need to comply with the new rules.
It's also important to note that many grandfathered plans already cover an array of preventive services with minimal or no cost sharing.
RN: How were these services chosen?
Dr. Seshamani: The ACA specifies that Medicare beneficiaries will not have to pay cost-sharing for Medicare-covered services that are recommended with a grade of A or B by the U.S. Preventive Services Task Force. The law also requires private plans to cover without cost-sharing all services that are recommended with a grade of A or B by the task force; routine immunizations recommended by the Advisory Committee on Immunization Practices; services for infants, children, and adolescents recommended by the Health Resources and Services Administration, including the Bright Futures guidelines for regular pediatric checkups, and guidelines on newborn screening; and additional preventive services for women that are being developed.
RN: How will this change affect primary care physicians? What about specialists?
Dr. Seshamani: Some of the recommended services, like flu shots, are routinely delivered by primary care physicians, while others, like colonoscopies, are more commonly delivered by specialists. All physicians have a role to play in making sure their patients get the preventive care they need to stay healthy.
RN: What proportion of the preventive services have patients been getting in the past, and what do you expect after these changes?
Dr. Seshamani: Many Americans have not gotten the preventive care they need, often because of cost. Before the ACA, Americans used preventive services at about half of the recommended rate. By eliminating copayments for new plans and for Medicare beneficiaries, the law will make preventive care more accessible for many Americans.
RN: Won't these changes increase public and private health care costs, while health reform was supposed to control costs?
Dr. Seshamani: Chronic diseases, such as cancer, heart disease, and diabetes make up 75% of U.S. health spending. These diseases are often preventable, and by improving access to preventive care, more Americans will get the care they need to stay healthy. This can not only improve the health of Americans, but also prevent the need for costly care later.
The complete list of preventive services that Medicare and some private plans must offer at no charge to patients is at http://www.HealthCare.gov/center/regulations/prevention.html
Before the ACA, Americans used preventive services at about half of the recommended rate.