Although eight new prevention-related health care services for women included in the Patient Protection and Affordable Care Act are now available at no cost to female patients, insurance brokers and industry experts are left wondering about the real price tag.
Tanya Boyd, owner of Sunnyvale, Texas-based Tanya Boyd & Associates, believes the Department of Health and Human Services and the Obama administration should not tout the word "free" when talking about health care coverage. "It is completely misleading," she says.
Free is more of a fallacy and should be replaced with the more appropriate word "covered," when talking about health care services covered for women, adds Reid Rasmussen, owner of McKinney, Texas-based Benefit Brainstorm. "While many call these 'free' services, there is still a cost that's being shared by Americans who are buying insurance," he says.
As of Aug.1, 2012, the new rules in the health care law requiring coverage of these services take effect at most health insurance plans' next renewal date.
The services are expected to cover 47 million women, and the total number of prevention-related health care services for women climbs to 22, rising from 14 that became effective in September 2010, according to the federal government. The eight new prevention-related services are based on recommendations from the Institute of Medicine, which polled independent physicians, nurses, scientists and other experts, as well as evidence-based research, to develop its recommendations (see sidebar on p.54 for a list of the new covered services).
Non-grandfathered group health plans offering group or individual health insurance coverage must provide coverage for preventive care without any cost-sharing requirements such as co-payments, co-insurance or deductibles, as long as services are administered by physicians and other health care professionals who participate in the plan's network.
Group health plans and issuers that have maintained grandfathered status are not required to cover these preventive services. In addition, certain nonprofit religious organizations, such as churches and schools, are also not required to cover these services.
HHS and the Obama administration feel confident about the services that are now being provided to women. "President Obama is moving our country forward by giving women control over their health care," says HHS Secretary Kathleen Sebelius. "This law puts women and their doctors, not insurance companies or the government, in charge of health care decisions."
But Boyd claims that the services were already readily available to women who needed and wanted them. "Many women who put health care at the top of their priority list have always had the services done, whether they paid a co-pay, found a clinic that provided services for free, or paid 100% out of their pocket," Boyd says. "Now insurance companies are forced to pay for these services, which will be reflected in the premiums we all pay."
Boyd doesn't doubt that early detection through preventive care is in the best interest of everyone involved, but the reality is, "that no one can force anyone to do anything," she says.
In the insurance industry there is always a lot of cost-sharing and cost-shifting to support the introduction of new covered lives, or new benefits, but it's too soon to tell how these costs will be reflected, adds Robin Gelburd, president of New York City-based FAIR Health, a national nonprofit advocating health care transparency.
"In making these preventive services available to women there's a recognition and a paradigm shift, not just due to PPACA, but in general.
"People have been remarking that our health care is really 'sick care' and in order to make it 'wellness care' we should put emphasis on preventive services," she says. "At the end of the day, there could be some cost reductions that one could point to for introducing these new services."
This is part of the White House's argument. An April 2012 report, "Keeping America's Women Moving Forward," notes a study that finds "more than 50% of women delayed seeking medical care because they couldn't afford it, compared to 39% of men."
Such delays can prove costly when as a result of waiting too long the patient now needs more extensive (and expensive) treatment.
In his role at global insurance brokerage Willis, Jay M. Kirschbaum helps employers maintain plan compliance. "Adding low-cost mandates is just another item on the checklist," says the practice leader for the national legal and research group at Willis' human capital practice.
And offering these preventive services free of charge to women seems to be more costly than it's worth, Kirschbaum believes. He believes that none of the services cost women a large amount of money out-of-pocket, at the most a couple hundred dollars for a well-woman visit, which he believes is not a lot of money.
These new services look familiar to Joseph Berardo, CEO and president of New York City-based MagnaCare. Most employer-based health care, Medicare risk plans and Medicaid risk plans cover preventive health care services already, at least 80% to 90% of plans, he says.
Benefit Brainstorm's Rasmussen agrees. "Although PPACA legislates some great wins for many Americans, including women, some of the eight new services were included under many medical plans pre-PPACA," he says.
In addition, Rasmussen believes that "many women don't need or won't take advantage of these services."
But for those who do take advantage of the opportunity, insurance companies will need to fund the services all the same, leading them to spread the costs across all policy holders, he says.
During her presentations throughout Louisiana and Mississippi, B. Ronnell Nolan, president of Baton Rouge, La.-based Nolan Group and lobbyist for the Louisiana Association of Health Underwriters, is very vocal when it comes to her stance on health care reform.
"You will always hear me say, 'There is nothing affordable in the Patient Protection and Affordable Care Act,'" she says. "The cost was not addressed, and health insurance premiums are expensive because health care is expensive."
Women need to be informed purchasers of health care, says FAIR Health's Gelburd. "Education is important when it comes to affordable services," she says.
FAIR Health, an independent, not-for-profit corporation, was established in October 2009, as part of the settlement of an investigation by then New York State Attorney General Andrew Cuomo into the health insurance industry's methods for determining out-of-network reimbursement.
"Will we see increases in utilization to show that women are availing themselves of these new services so there is a public health benefit with less strain on the health care system?" Gelburd asks.
Although the services are free, Gelburd emphasizes that employees must know which procedures fit into preventive-related health services coverage. "Transparency of costs has to move to the front to ensure [women] are not in an unsuspecting way lured in and think that these [procedures] will be free," she adds.
Questions for the future
These additional preventative health care services for women have been in the works since August 2011, when HHS issued an interim final rule that required most health insurance plans to cover preventive health services for woman, including recommended contraceptive services without charging a co-pay.
Since that time, insurance companies have been planning for the additional costs, Rasmussen says. However, he says the problem with mandating specific coverage is that it removes freedom of choice from the equation - as well as the ability to choose different plans with less coverage (and lower costs). "Mandated coverage drives up all insurance costs because you can [no longer] create differentiated plans for a differentiated America," he says.
Nolan agrees. "Insurance companies cannot afford to give away benefits for free. While [employees] may not pay up front deductibles and co-payments, [they] are paying on the back end, guaranteed," she says.
Boyd echoes the sentiment that one way or the other Americans are going to pay for the preventive-related health care services: "All of this 'free' stuff is going to be very expensive."
New Preventive Health Services For Women
1. Well-woman visits
2. Gestational diabetes screening that helps protect pregnant women from one of the most serious pregnancy-related diseases
3. Domestic and interpersonal violence screening and counseling
4. FDA-approved contraceptive methods, and contraceptive counseling and education
5. Breastfeeding support, supplies, and counseling
6. HPV DNA testing, for women 30 or older
7. Sexually transmitted infections counseling for sexually-active women
8. HIV screening and counseling for sexually-active women
Source: Department of Health and Human Services
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