WASHINGTON (AP) — It's one part of the new health care law that seemed clear: free coverage for preventive care under most insurance plans.
Only it didn't turn out that way.
So on Wednesday, the Obama administration had to straighten out the confusion.
Have you gone for a colonoscopy thinking it was free, only to get a hefty bill because the doctor removed a polyp?
Taking out such precancerous growths as part of a routine colon cancer screening procedure will now be considered preventive care.
"Polyp removal is an integral part of a colonoscopy," the Department of Health and Human Services said in guidance posted on its website. That conclusion has the backing of several leading medical societies, the department noted.
Also addressed in the notice was genetic testing for breast cancer, coverage of over-the-counter products such as aspirin for heart care and nicotine patches for smoking, and birth control for women. Unlike formal regulations, the guidance does not have the force of law, but advocates for patients say insurers would be ill-advised to ignore it.
President Barack Obama's health care law required most private health plans to cover preventive care at no additional charge to patients. It also expanded preventive coverage without copayments for Medicare recipients. For workers and their families, the expense is borne by the company health plan, which passes on some of those costs in the form of higher premiums. Advocates say preventive care saves the health care system money over time.
Colonoscopy is an expensive test that can cost more than $1,000. It's recommended for adults 50 and over, and has become a rite of passage for aging baby boomers.
News that it would be covered free under the health care law got attention, but that was followed quickly by a letdown when many insurers started charging if a polyp or two was discovered and removed during the procedure.
"Insurers were reclassifying it from a preventive test to a diagnostic procedure," said Stephen Finan, policy director for the American Cancer Society Cancer Action Network. "In some cases the cost-sharing was a significant amount of money."
His group was among several that complained to the administration.
Other free preventive services addressed in Wednesday's guidance:
—Insurers must cover testing, if ordered by a doctor, for rare BRCA genes that dramatically increase the risk of breast cancer. Such tests can cost as much as $3,000.
—Over-the-counter products such as aspirin for heart care and nicotine patches for smoking cessation are covered with a doctor's prescription.
—Insurers won't be able to fulfill the law's requirement to cover contraception as preventive care for women if they only pay for birth control pills. A full range of FDA-approved methods must be covered, including long-acting implant and intrauterine devices. Birth control methods for men are not covered as preventive care.
If a health plan does not have a network doctor who performs a particular preventive service, a patient can see a doctor out-of-network without facing copays or additional charges.
The insurance industry said the requirement to cover over-the-counter medications will lead to higher costs. "We are concerned about the precedent of requiring health plans to provide coverage for over-the-counter drugs, such as aspirin and iron supplements, that are not typically covered by insurance today," said Robert Zirkelbach, spokesman for America's Health Insurance Plans, an industry trade group.
Also Wednesday, the government came out with final rules on the benefits that health plans catering to individuals and small businesses will have to offer starting next year, when new insurance markets called exchanges open in each state.
The coverage generally is better than what's now available to people buying individual policies, but close to what medium-size companies offer, with some important improvements in areas such as mental health care.
Benefits include hospital and outpatient care, emergency services, maternity and newborn care, prescriptions, prevention, rehabilitation and ongoing assistance for people with potentially disabling conditions, and dental and vision care for children.
All plans will have to cover the same benefits, but their premiums and cost sharing will vary. There will be four level of coverage — bronze, silver, gold and platinum. Bronze plans will cover 60 percent of expected costs while platinum plans will cover 90 percent.
Health and Human Services Department: http://tinyurl.com/au6lzeo
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