Getting the Coverage You Deserve: What to Do if You Are Charged a Co-Pay, Deductible, or Co-Insurance for a Preventive Service

The health care law requires new health plans to cover certain preventive services. This means that, as an increasing number of health plans come under the law's reach over the next few years, more and more people will have access to a wide range of preventive services without co-payments, deductibles, or co-insurance. This is especially important to women, who are more likely than men to avoid needed health care, including preventive care, because of cost. This requirement is a huge step forward for women's health.The National Women's Law Center has been working hard to make sure women and their families know about the preventive coverage provided through the health care law. We've heard from many women about how much this coverage has helped them but we've also heard about some women encountering problems while trying to get these services without cost sharing. This toolkit is designed to provide women with information on the coverage of preventive services in the health care law and tools they can use if they encounter problems with this coverage. We have also provided detailed instructions on how to file an appeal with insurance companies and draft appeal letters on a range of preventive service

Association between health insurance literacy and avoidance of health care services owing to cost

Importance: Navigating health insurance and health care choices requires considerable health insurance literacy. Although recommended preventive services are exempt from out-of-pocket costs under the Affordable Care Act, many people may remain unaware of this provision and its effect on their required payment. Little is known about the association between individuals\u27 health insurance literacy and their use of preventive or nonpreventive health care services. Objective: To assess the association between health insurance literacy and self-reported avoidance of health care services owing to cost. Design, Setting, and Participants: In this survey study, a US national, geographically diverse, nonprobability sample of 506 US residents aged 18 years or older with current health insurance coverage was recruited to participate in an online survey between February 22 and 23, 2016. Main Outcomes and Measures: The validated 21-item Health Insurance Literacy Measure (HILM) assessed individuals\u27 self-rated confidence in selecting and using health insurance (score range, 0-84, with higher scores indicating greater levels of health insurance literacy). Dependent variables included delayed or foregone preventive and nonpreventive services in the past 12 months owing to perceived costs, and preventive and nonpreventive use of services. Covariates included age, sex, race/ethnicity, income, educational level, high-deductible health insurance plan, health literacy, numeracy, and chronic health conditions. Analyses included descriptive statistics and bivariate and multivariable logistic regression. Results: A total of 506 of 511 participants who began the survey completed it (participation rate, 99.0%). Of the 506 participants, 339 (67.0%) were younger than 35 years (mean [SD] age, 34 [10.4] years), 228 (45.1%) were women, 406 of 504 who reported race (80.6%) were white, and 245 (48.4%) attended college for 4 or more years. A total of 228 participants (45.1%) had 1 or more chronic health condition, 361 of 500 (72.2%) who responded to the survey item had seen a physician in the outpatient setting in the past 12 months, and 446 of the 501 (89.0%) who responded to the survey item had their health insurance plan for 12 or more months. One hundred fifty respondents (29.6%) reported having delayed or foregone care because of cost. The mean (SD) HILM score was 63.5 (12.3). In multivariable logistic regression, each 12-point increase in HILM score was associated with a lower likelihood of both delayed or foregone preventive care (adjusted odds ratio [aOR], 0.61; 95% CI, 0.48-0.78) and delayed or foregone nonpreventive care (aOR, 0.71; 95% CI, 0.55-0.91). Conclusions and Relevance: This study\u27s findings suggest that lower health insurance literacy may be associated with greater avoidance of both preventive and nonpreventive services. It appears that to improve appropriate use of recommended health care services, including preventive health services, clinicians, health plans, and policymakers may need to communicate health insurance concepts in accessible ways regardless of individuals\u27 health insurance literacy. Plain language communication may be able to improve patients\u27 understanding of services exempt from out-of-pocket costs

Providing Preventive Oral Health Care to Infants and Young Children in Women, Infants, and Children (WIC), Early Head Start, and Primary Care Settings

This report focuses on seven oral health programs that provide preventive oral health care to young children (infants, toddlers, and children up to 5 years old) in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), Early Head Start (EHS), and primary care settings. All of the programs strive to increase access to preventive oral health care by integrating dental services into primary care settings, WIC clinics, or EHS centers. These programs also rely on primary care providers (physicians, nurses, medical assistants, etc.) or new types of dental hygienists who can practice in community settings to deliver preventive oral health services. Two additional reports in this series describe the remaining programs that provide care in non-dental settings and programs designed to specifically address socioeconomic, cultural, and geographic barriers to preventive oral health care.The findings from the EAs of these programs are synthesized to highlight diverse and innovative strategies that are utilized to provide preventive oral health care in primary care settings, WIC clinics, or EHS centers. These strategies have potential for rigorous evaluation and could emerge as best practices. If proven effective, these innovative program elements could then be disseminated and replicated to increase access for populations in need of preventive oral health care

Preventive Care, Care for Children and National Health Insurance

The purpose of this paper is to examine issues related to the coverage of preventive care under national health insurance. Four specific kinds of medical care services are included under the rubric of preventive care: prenatal care; pediatric care, dental care, and preventive physicians' services for adults. We consider whether preventive care should be covered under national health insurance, and if so what is the nature of the optimal plan. Our review of the literature on the effects of medical care on health outcomes suggests that prenatal care and dental care are effective, but pediatric care (except for immunizations) and preventive doctor care for adults are not. Moreover, health outcomes in which care is effective correspond to outcomes in which income-differences in health are observed. These empirical results and the theory of health as the source of consumption externalities indicate that the optimal NHI plan should be characterized by benefits that fall as income rises. In addition, the plan should be selective rather than general with respect to the types of services covered.

Health Savings Account - Eligible High Deductible Health Plans: Updating the Definition of Prevention

High-deductible health plans (HDHPs) are an important and growing part of the health insurance landscape. By some estimates, as many as 80 percent of large employers may offer an HDHP in 2014. In 2013, more than 15 million Americans received health coverage through an HDHP, a more than a threefold increase since 2007.As outlined by the U.S. Treasury Department, individuals with an HSA-eligible HDHP are required to pay the full cost of most medications and services -- in theory utilizing pre-tax HSA funds -- until deductibles are met. However, the 2003 authorizing legislation and further guidance include a safe harbor allowing plans to cover primary preventive services, those typically deemed to prevent the onset of disease, before the deductible is satisfied.Services or benefits meant to treat "an existing illness, injury or condition," are excluded from first-dollar coverage in HSA-eligible HDHPs, which encompasses most secondary preventive services. For example, plans are prohibited from providing first dollar coverage of disease management services such as insulin, eye and foot exams, and glucose monitoring supplies for patients with diabetes.As chronic disease conditions currently make up 75 percent of total U.S. health spending, appropriate chronic disease management is an important tool to lower long-term health care costs. As the market for HDHPs grow, it is important that they maintain the flexibility to allow for effective health management of all beneficiaries. This report addresses the strict definition of prevention that an HDHP must follow for it to include a pre-tax health savings account (HSA), and how this restriction limits the effectiveness of current plans. A potential solution - allowing HSA-eligible HDHPs to provide first-dollar coverage for targeted, evidence-based, secondary preventive services that prevent chronic disease progression and related complications - can improve patient-centered outcomes, add efficiency to medical spending, and enhance HDHP attractiveness.A multi-disciplinary research team from the University of Michigan's Center for Value-Based Insurance Design, Harvard Medical School, and the University of Minnesota conducted a multi-part project to investigate the impact of updatingthe definition of prevention for HDHPs to include selected secondary preventive services that are frequently used as health plan quality metrics and included as elements of pay-for-performance programs. Specifically, the project aimed to: 1) determine the premium effect, actuarial value, and estimated market uptake of the novel HDHP plan that covers these evidence-based services outside the deductible, and 2) explore through interviews whether insurance industry experts found coverage of secondary preventive services a worthwhile endeavor

A Public Health Framework for Screening Mammography: Evidence-Based Versus Politically Mandated Care

This Viewpoint highlights the societal risks of politically motivated mandates relating to public health guidelines. Although the Affordable Care Act mandated insurance coverage for U.S. Preventive Services Task Force (USPSTF)-recommended preventive services, it went further for mammography screening. Instead of relying on the most recent USPSTF guidelines, Congress amended the ACA to require the Department of Health and Human Services (DHHS) to use its 2002 guidelines, which recommended screening every 1-2 years starting at age 40. The FY 2016 Consolidated Appropriations Act instructs DHHS to interpret any reference to “current” USPSTF breast cancer screening recommendations to mean those issued “before 2009” — in other words, its 2002 recommendations. Essentially, Congress is requiring health insurers to ignore modern scientific assessments, and instead use 14-year-old guidance. The ACA improved the public’s health by guaranteeing that insurers provide uniform, cost-free access to preventive services based on modern evidence of effectiveness. The public’s health is best served when women’s personal decisions about screening are informed by evidence rather than political considerations. The Congress’s paternalistic response to USPSTF mammography-screening recommendations vividly illuminate the social costs of politically mandated care. Rather than benefiting women, political interference with science can discourage shared decision-making, increase harms from screening, and sow public doubt about the value and integrity of science

The quality of preventive and diagnostic medical care: why do southern states underperform?

As the cost of health care increases rapidly, the health care industry has turned its attention to methods of cost containment. However, concern exists that the drive to contain costs could lead to compromises in the quality of medical care. One practice that may slow the growth rate of health care expenditures and improve morbidity and mortality rates is the widespread use of preventive and diagnostic services. ; Using data compiled by the Centers for Medicare and Medicaid Services, this article evaluates the quality of care received by Medicare beneficiaries in each state. The authors examine states’ use of preventive services (influenza and pneumococcal immunizations) and diagnostic services (mammograms and diabetes screening tests) among Medicare beneficiaries. ; The analysis points out regional differences in preventive and diagnostic care across the United States. The West has higher levels of preventive care while the Northeast has higher scores for diagnostic care. But the South had the lowest average score for quality of care in both categories. The authors attribute differences among states’ levels of preventive and diagnostic care to their socioeconomic and demographic characteristics, noting in particular that the percentage of a state’s Medicare population that is black is inversely related to the quality of medical care. ; A better understanding of the causes behind racial disparities in the quality of medical care, the authors conclude, will promote the delivery of the highest quality of care to all Medicare beneficiaries and slow the growth rate of health care costs.

Improving Child Health Care Through Federal Policy: An Emerging Opportunity

Summarizes legislative proposals introduced in 2007 to track primary care outcomes in Medicaid and State Children's Health Insurance Programs (SCHIP) and focus on strengthening primary, preventive, and developmental child health services and research

Knowledge of Healthcare Legislation and Use of Preventive Health Services in the Tallahassee-Leon County area of northwest Florida in the United States

Research evidence indicates that racial/ethnic minorities in the United States, including African Americans, have low rates of access to and use of health care, including preventive health services. The implementation of the Patient Protection and Affordable Care Act (ACA) has afforded health insurance coverage and increased access to preventive health services for eligible Americans. Despite the ACA provision of free access to preventive health services, there remains a gap in the use of those services by ethnic minorities. It is not clear whether that gap is due to lack of health insurance or lack of knowledge about the ACA provision. This study examines the extent to which knowledge or familiarity with the Act enhances the use of preventive health services among African Americans in the Tallahassee-Leon County area of northwest Florida. It used primary data collected from a survey conducted during March-April 2012 among a sample of self-identified African American adults in the area. The Statistical Package for the Social Sciences (SPSS) Version 22 was used for running frequency analysis on the dataset, which indicated that although majority of insured respondents used preventive health services, some of the insured did not use preventive services because they were unfamiliar with the ACA provision of free access to preventive services for insured people. Health promotion and awareness campaigns about the law’s benefits by local and state health departments can enhance the use of preventive services

Leading causes of death and probabilities of dying, United States, 1975 and 1976

U.S. Department of Health, Education, and Welfare, Public Health Service, Center for Disease Control, Bureau of State Services, Health Analysis and Planning for Preventive Services.Chiefly tables."99-208."Issued March 1979