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Twice in the last two years, I have been informed that I must pay for preventive services as I had not satisfied my deductible. In both cases, I owed nothing, and the full amount was ultimately paid by my insurance company. The demand for my payment was the result of a health insurance claim coding error by the billing staff of my medical group. One would think that the billing staff of one of the largest medical groups in New Jersey would know how to correctly bill New Jersey's largest health insurance company for routine services, but obviously not.
If you have insurance through your employer or buy health insurance on your own, with or without a government subsidy, you are entitled to an array of preventive care services without any cost-sharing — no copayment, coinsurance, or deductible. The exception is if you are covered by a plan that has been essentially unchanged since 2010. "Grandfathered" plans are increasingly uncommon. If you or your employer purchase insurance from a state or federal-operated health insurance marketplace, you have a non-grandfathered plan.
Per the Affordable Care Act (ACA), non-grandfathered plans must provide a minimum list of preventive care services without cost sharing. Furthermore, plans can optionally expand the list of preventive services. One common expansion is to cover one preventive care office or clinic visit per year for everyone. That's because the ACA only mandates a preventive "wellness" office visit coverage for women and children even though preventive services are almost always ordered or provided in during an office visit.
If you have a high deductible health plan that qualifies for a health savings account, the IRS limits what services may be optionally classified as preventive and exempted from the high deductible. In 2019, the IRS expanded the list of permitted preventive care services to include services well beyond the ACA minimum, including certain tests and treatments for specified chronic conditions. Most notably the IRS allows insulin and other glucose-lowering agents to be optionally covered for people with diabetes. Some self-insured employers have expanded preventive coverage to the IRS maximum.
Screening colonoscopies are particularly prone to misbilling. In 2015, multiple agencies of the federal government made it clear that a screening colonoscopy must be covered under private, non-grandfathered health plans (Medicare has different rules for colonoscopies) as a preventive service, without any cost-sharing, and that the coverage must include anesthesia and pathology, even if polyps are found. Yet patients continue to be billed for some, and sometimes all, of their screening colonoscopy services.
The mandate for contraceptive preventive services continues to be contentious. While most health plans cover contraceptive services, some plans object to providing the coverage and claim a religious or moral exemption. When they do, they can notify the federal government, which will then provide contraceptive services to the covered person without cost to the plan. Some objecting plans refuse to provide the notification. Therefore, in January 2023, the federal government proposed a rule that will provide women covered under such plans direct access to government-paid contraception without any plan involvement. The rule is not yet final (as of the end of May).
One of the areas of administrative confusion is intent. Diseases can be diagnosed and even minimally treated during a preventive care service if the service is performed with the intent of providing preventive care. Therefore, a screening colonoscopy is a preventive service even if polyps are found and removed (except if you are covered by Medicare). Likewise, your physician can update your blood pressure prescription during an annual wellness visit. If the physician puts a preventive services diagnosis code in the first position on the list of diagnosis codes submitted with the claim, a claim for a covered preventive service will generally be paid by your plan as a preventive service.
If you think that you have been inappropriately charged for a preventive service, you should check your plan's "Summary of Benefits and Coverage" and other plan documents. You should then reach out to both your medical provider and your health plan, ideally in writing and, if the issue remains unresolved, file a written appeal. If your plan is "fully insured" you can also contact your state's Department of Insurance. If your plan is "self-insured" via your large employer or union, you can contact your employer/union and the Department of Labor.
Even though I provided my medical group and health plan with the 2015 federal clarification, they insisted that I needed to pay for the anesthesia for my colonoscopy and threatened to send my bill to collections for non-payment. They, however, quickly "discovered" that they had miscoded the claim after I reached out to the New Jersey Department of Banking and Insurance, Division of Insurance.
More recently, a discussion of a minor ailment during an annual well-visit caused my medical group to code the visit as an acute care visit. After a couple of rounds of discussion, I convinced the medical group to re-code the claim to properly show it was a preventive visit.
Yes, health insurance is hard, even for a health insurance expert.