Patient Alert: When ‘free’ isn’t free!

Volume 116, No. 4April, 2016

Martha Hyde

Under the Affordable Care Act, Qualified Health Plans (QHPs) are required to cover certain preventive services 100 percent without co-pays, deductibles or coinsurance. This is intended to encourage folks to get tested and screened so if there are any major problems they can be addressed before they become life threatening. Two of these services are mammograms and colonoscopies.

Mammogram screenings are generally recommended for women over 40 and colonoscopies are recommended for anyone over 50. However, you can be subject to unexpected charges. For example: if you have a colonoscopy in an outpatient surgery center or a hospital, your insurance may require you to share the cost of the facility. (Our own Local 802 health plan does have this requirement.) Check with your insurance company before having the procedure.

You also need to be sure the doctor performing the procedure codes it as a “screening” and not some other kind of procedure. If you are asked any leading questions about whether or not you have ever seen blood in your stool, beware. It could lead to the procedure getting coded as “diagnostic” (meaning you have symptoms) and you may be subject to a number of co-pays, coinsurance or deductibles for the procedure. If you are concerned about your risk of colon cancer, by all means be transparent and truthful with your doctor. But if not, don’t be afraid to ask if the procedure will be coded as a screening.

Also, be aware that “surveillance” and “screening” do not necessarily mean the same thing. A healthy adult over 50 with no history of polyps or family history of cancer is usually entitled to a screening every five to 10 years. If it’s been five years or fewer since your last screening and you hear your doctor saying the word “surveillance” or see that on any form, question the doctor about that. Only a screening is sure to be considered preventive and thus covered 100 percent.

Finally, I have spoken to a number of people who have unexpectedly received 3D mammograms. Mammogram screenings are covered 100 percent but a 3D mammogram is much more expensive and because it has not been studied enough for effectiveness and because it exposes the patient to additional radiation, many insurance policies will not cover it 100 percent. Local 802 does not cover 3D mammograms as a preventive service with no co-pay Check before you have the procedure to see if you are expected to undergo the traditional mammogram or a 3D and make sure you know what your insurance will cover.

For all preventive services, if your insurance is restricted to a network, make sure you stay in network. The “100 percent payment rule” only applies to in-network services.