"Preventative Care" in the ACA...a flaw

[SHRED]

Many procedures in preventative care are covered 100% by the ACA.
Here's the "flaw". If you have a sore breast let's say and you go in for a mammogram then that is not covered as preventative care since you went in with a problem.
This, I think, discourages people from discussing health issues in hopes it is caught in routine preventative care.
Do other's here think this is an issue?

[Aristus]

1. I would think it would depend upon the findings of the clinical provider.

If a provider orders a mammogram over nothing more than a 'sore breast', insurance might not pay. But if clinical exam reveals any sign of potential breast cancer (breast mass, spontaneous nipple discharge, changes to the shape or skin of the breast, peau d'orange, retracted nipple, etc,) a mammogram then becomes clinically indicated and should be paid for by insurance. Or at least by a smart insurance company, that recognizes that preventing or treating early-stage breast cancer is a hell of a lot cheaper than treating late-stage cancer, or a mastectomy.

[Cal Carpenter]

5. "Should" is the operative word

But we're dealing with the real-world, for-profit health care system, not hypothetical 'smart' insurance companies... Due to co-pays, co-insurance, and deductibles, most people are paying out of pocket (in significant amounts, if not in full) for this type of thing because it isn't considered 'preventative' except in a figurative sense. Doesn't matter if it is clinically indicated or not. If it isn't part of the annual check-up or once-every-two-years routine mammogram (or whatever is considered routine/preventative), then the OOP expenses apply.

I think the OP brings up a good point.

[WillowTree]

9. Not the way it works t all.

If a mammogram (or pap smear or blood work or whatever) is ordered as part of a routine, annual exam (no diagnosis), then it's considered to be preventive in nature and coverd at 100%; no deductible, no copay.

If, however, it is ordered in response to symptoms (doctor will provide a diagnosis), then it would still be covered, but subject to the regular plan deductible and co-insurance rate.

[MineralMan]

2. Well, if you come in with a complaint that requires

a diagnostic procedure, it's not preventative care in the first place. You had a health issue when you came in. If you have health insurance, the procedure will be covered under the terms of the policy. You may have a co-pay or your deductible may not have been covered.

I'd prefer universal, single-payer healthcare, but we don't have that yet. Medicare for all would work, but you'd still have a monthly premium. Even people over 65 pay a monthly premium for both Medicare Part B and any supplemental insurance they carry. Some opt for a Medicare Advantage plan, but will still pay a premium.

If Medicare for all is put into place, people under 65 will pay a higher premium, since they are not yet of an age to be covered by Medicare. How much that will be is anyone's guess right now, since the calculations haven't been done.

Preventative care is care you get when you have no complaint. The annual comprehensive physical fits into that category. Some diagnostic tests also qualify for 100% coverage, but again, when they are scheduled as preventative care. If a test is needed for an issue you come to the doctor about, that's not preventative care.

[B Calm]

3. Doesn't your free yearly wellness exam cover mammograms?

[tammywammy]

8. Routine mammograms are recommended starting at 40.

An annual mammogram would be covered as preventative. I'm 35 if I find a lump during a breast exam and my doctor sends me for a mammogram it's a diagnostic exam and not preventative.

[KentuckyWoman]

4. Not covered at all or not covered at 100%?

I'm not try to pick nits it's just that this one is new to me and I'm just trying to clarify.

Kynect does a lot of business in my neck of the woods and I have not heard about this at all. Would like to spread the word.

Bottom line though is one mammogram a year should be covered at 100% whether it's routine or diagnostic. If it isn't now then we need to get a change in that. That said, if you think it might be breast cancer paying for mammogram as "diagnostic" rather than "preventative" is the probably the least of your worries.

[Ms. Toad]

7. If it is ordered in response to complaints, it is diagnostic & covered

at the normal coinsurance rate.

If it is your routine mammogram - not being done because you have symptoms - it is preventative.

I don't have a problem with that. The test is ordered as a diagnostic tool.

What I DO have a problem with is conversion mid-stream.

Preventative colonoscopies are covered once you hit age 50. BUT if they find something they need to biopsy you are on the hook not only for the biopsy, but for the colonoscopy. That is different than any other preventative care service.

Your mammogram doesn't become diagnostic because they found a suspicious spot. Further tests are diagnostic, but the original mammogram is still preventative.

Your annual bloodwork doesn't become diagnostic because whatever they are testing is out side the normal range. Further tests are diagnostic, but the original bloodwork is not.

Colonoscopies SHOULD work the same way. Your initial colonoscopy, start to finish, should be covered. The biopsies, themselves, are further tests that are diagnostic - but if you went in without symptoms, the colonoscopy itself is NOT diagnostic. You could probably get around it by saying, "If you find anything, just leave it and we'll come back later to get the biopsy." But that would be silly. And with coinsurance ranging from 10% to 30% (or more), the coinsurance is a few hundred dollars you were not expecting to pay when you rolled out of bed that morning.

[KG]

6. ACA , LOL.

[procon]

10. No, its not an issue because there is a difference between preventative and diagnostic care.

This is not a new concept, and it did not just pop up suddenly under ACA, this is normal. What's new, is that thanks to the Affordable Care Act, insurance now covers preventive mammograms with no cost sharing or out-of-pocket cost to the patient.

Beyond the preventive mammogram to screen for cancer, a medical issue is a diagnostic mammogram and your coverage and fees would depend on whatever plan you chose. It's difficult to believe that the scenario you describe would actually exit. Poor women are covered and often have no out of pocket fees through the medicaid expansion, and mammograms for patients with other plans would still be covered either in whole or in part, with a just as any other diagnostic xray for a pain in your knee.