If you’re like most agents, you’re probably hearing a lot of complaints from your individual health insurance clients these days. There is, after all, plenty to complain about: higher premiums, higher out-of-pockets, reduced formularies, smaller provider networks, and fewer carriers offering plans. Once covered, a lot of people end up paying for most of their care themselves since a majority of services are subject to the calendar-year deductible, leading some to question why they have health insurance at all.
When faced with this question, agents normally point out that the real reason for insurance isn’t to cover lower-cost services like doctor visits and prescriptions but rather to protect people against big, unexpected claims. In the same way that you need homeowner’s insurance in case your house burns down, you need health insurance in case you wind up in the hospital. That’s a true statement, but if your clients still don’t see the value in today’s plans, we have another idea. Why not point out the features of the policy they might actually use?
The one thing that all ACA plans in all market segments have in common is that they cover up-front preventive care with no cost-sharing, when services are received from in-network providers. This is an important benefit, and with more and more services subject to today’s very high deductibles, it’s the one bill the insurance company will pay in full. For that reason, it’s important for brokers to make sure their clients are aware of all of the preventive services they have access to.
As explained on the Healthcare.gov website, the ACA’s preventive care requirements fall into three categories: preventive services for all adults, preventive services specifically for women, and preventive services for children.
PREVENTIVE CARE FOR ALL ADULTS
All ACA-qualified health plans (all non-grandfathered plans) must cover the following list of preventive services without charging a copayment or coinsurance even if the member hasn’t met his or her yearly deductible.
- Abdominal aortic aneurysm one-time screening for men of specified ages who have ever smoked
- Alcohol misuse screening and counseling
- Aspirin use to prevent cardiovascular disease for men and women of certain ages
- Blood pressure screening
- Cholesterol screening for adults of certain ages or at higher risk
- Colorectal cancer screening for adults over 50
- Depression screening
- Diabetes (Type 2) screening for adults with high blood pressure
- Diet counseling for adults at higher risk for chronic disease
- Hepatitis B screening for people at high risk, including people from countries with 2% or more Hepatitis B prevalence, and U.S.-born people not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence.
- Hepatitis C screening for adults at increased risk, and one time for everyone born 1945 – 1965
- HIV screening for everyone ages 15 to 65, and other ages at increased risk
- Immunization vaccines for adults — doses, recommended ages, and recommended populations vary. There is a long list of covered immunizations, including Hepatitis A and B vaccines, the flu shot, and vaccines for measles, mumps, and chickenpox.
- Lung cancer screening for adults 55 – 80 at high risk for lung cancer because they’re heavy smokers or have quit in the past 15 years
- Obesity screening and counseling
- Sexually transmitted infection (STI) prevention counseling for adults at higher risk
- Syphilis screening for adults at higher risk
- Tobacco Use screening for all adults and cessation interventions for tobacco users
PREVENTIVE CARE FOR WOMEN
In addition to the list of preventive services for all adults, there are a number of additional preventive services that must be provided at no charge to women, when services are received from in-network providers.
Services for pregnant women or women who may become pregnant
- Anemia screening on a routine basis
- Breastfeeding comprehensive support and counseling from trained providers, and access to breastfeeding supplies, for pregnant and nursing women
- Contraception: Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a health care provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”
- Folic acid supplements for women who may become pregnant
- Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes
- Gonorrhea screening for all women at higher risk
- Hepatitis B screening for pregnant women at their first prenatal visit
- Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
- Syphilis screening
- Expanded tobacco intervention and counseling for pregnant tobacco users
- Urinary tract or other infection screening
Other covered preventive services for women
- Breast cancer genetic test counseling (BRCA) for women at higher risk
- Breast cancer mammography screenings every 1 to 2 years for women over 40
- Breast cancer chemoprevention counseling for women at higher risk
- Cervical cancer screening for sexually active women
- Chlamydia infection screening for younger women and other women at higher risk
- Domestic and interpersonal violence screening and counseling for all women
- Gonorrhea screening for all women at higher risk
- HIV screening and counseling for sexually active women
- Human Papillomavirus (HPV) DNA test every 3 years for women with normal cytology results who are 30 or older
- Osteoporosis screening for women over age 60 depending on risk factors
- Rh incompatibility screening follow-up testing for women at higher risk
- Sexually transmitted infections counseling for sexually active women
- Syphilis screening for women at increased risk
- Tobacco use screening and interventions
- Well-woman visits to get recommended services for women under 65
PREVENTIVE CARE FOR CHILDREN
ACA plans must also cover the following list of preventive services for children with no cost sharing, when services are received from in-network providers.
- Alcohol and drug use assessments for adolescents
- Autism screening for children at 18 and 24 months
- Behavioral assessments for children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
- Blood pressure screening for children ages: 0 to 11 months, 1 to 4 years , 5 to 10 years, 11 to 14 years, 15 to 17 years
- Cervical dysplasia screening for sexually active females
- Depression screening for adolescents
- Developmental screening for children under age 3
- Dyslipidemia screening for children at higher risk of lipid disorders ages: 1 to 4 years, 5 to 10 years,11 to 14 years, 15 to 17 years
- Fluoride chemoprevention supplements for children without fluoride in their water source
- Gonorrhea preventive medication for the eyes of all newborns
- Hearing screening for all newborns
- Height, weight and body mass index (BMI) measurements for children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
- Hematocrit or hemoglobin screening for all children
- Hemoglobinopathies or sickle cell screening for newborns
- Hepatitis B screening for adolescents at high risk, including adolescents from countries with 2% or more Hepatitis B prevalence, and U.S.-born adolescents not vaccinated as infants and with at least one parent born in a region with 8% or more Hepatitis B prevalence: 11 – 17 years.
- HIV screening for adolescents at higher risk
- Hypothyroidism screening for newborns
- Immunization vaccines for children from birth to age 18 — doses, recommended ages, and recommended populations vary and include vaccines for whooping cough, measles, chickenpox, and much more.
- Iron supplements for children ages 6 to 12 months at risk for anemia
- Lead screening for children at risk of exposure
- Medical history for all children throughout development ages: 0 to 11 months, 1 to 4 years , 5 to 10 years , 11 to 14 years , 15 to 17 years
- Obesity screening and counseling
- Oral health risk assessment for young children ages: 0 to 11 months, 1 to 4 years, 5 to 10 years
- Phenylketonuria (PKU) screening for newborns
- Sexually transmitted infection (STI) prevention counseling and screening for adolescents at higher risk
- Tuberculin testing for children at higher risk of tuberculosis ages: 0 to 11 months, 1 to 4 years, 5 to 10 years, 11 to 14 years, 15 to 17 years
- Vision screening for all children
That’s a lot of preventive services that are covered at no cost to your clients, when they use in-network providers. Clearly, this long list of covered preventive benefits is not only something that they need to know about and take advantage of but also something that can help you sell the value of the plan. Will your clients suddenly be happy after reviewing the list of preventive services? Probably not. But they might be less unhappy, and anything you can do to improve the perceived value of the health plan that they’re likely paying hundreds of dollars per month for is a good thing. Client education goes a long way and will help differentiate you from many of your competitors.