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National Organizations Working to Ensure Preventive Services Fully Implemented

By Rebecca Adams, CQ HealthBeat Associate Editor

July 26, 2013 -- Implementing the health law requirement that insurers provide free preventive services remains a bit confusing for some patients and plans, especially when it comes to women's medical needs, say advocates, insurers, and physicians.

National groups are collecting examples of glitches that they hope can be fixed.

"We have been listening and have asked our physicians, 'Are you seeing any problems?" Jeanne Conry, president of The American Congress of Obstetricians and Gynecologists, said in an interview.

The National Women's Law Center has a toll-free hotline and an email account ([email protected]) devoted to helping women with any problems they are encountering in getting insurers to pay for contraception. The group plans to release a white paper on the issue later this year. Last month, it posted an updated "tool kit" on its website to help women understand what the health law requires and give them sample language to use with insurers that have inappropriately charged copays or refused to cover contraceptive benefits.

"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," said a 42-page booklet in the toolkit.

The provision requiring women to get contraception without copays or other cost sharing has gotten national note because some employers with religious objections have filed lawsuits attempting to avoid the mandate. Late last week, a federal circuit court of appeals refused to issue an injunction to one such company.

But so far, less attention has been paid to the practical problems with implementing the rules.

Anecdotally, physicians and patients report a range of problems, including difficulty in getting insurers to pay for long-acting contraception, such as IUDs or rings. Some women have been charged copays during a visit to get a contraceptive device inserted because a physician also gave the patient a pregnancy test, which is an important step to take before putting in a contraceptive device. ACOG also is watching to see if insurers are requiring doctors to prescribe one type of birth control, such as the pill, rather than longer-acting contraception, which is more expensive.

The health care law (PL 111-148, PL 111-152) requires all new or updated health plans to cover women's health preventive care, including contraception; breast-feeding support, supplies and counseling; screening for domestic violence; tests for gestational diabetes; DNA testing for high-risk strains of human papilloma virus; counseling for sexually transmitted infections, including HIV, and HIV testing; and check ups. The provisions took effect almost a year ago, on Aug. 1, 2012, for new plans or those that make substantial changes to their benefits.

A separate part of the law that took effect in 2010 requires coverage of a broad range of preventive services including such women's health benefits as mammograms, genetic testing for cancer, prenatal exams, smoking cessation and diabetes counseling.

An Implementation Challenge

Insurers acknowledge that there may be implementation problems, but say they are working hard to properly understand the provision and implement it the right way.

"We do know that there have been some coding challenges," said Susan Pisano, a spokeswoman for America's Health Insurance Plans. "It has to be coded as a preventive benefit to be paid that way and there's still some issues with that that could come into play." For instance, some doctors may use a billing code that insurers recognize as an office visit but the physician may fail to add a modifier identifying the visit as one for preventive care.

Pisano said it is difficult to talk about specific cases without knowing all the details.

One question patients who believe they have been inappropriately charged copays or denied coverage have to ask is whether the plan has to comply. Plans that are grandfathered—those that existed when the law passed in March 2010—do not have to provide the coverage until they make significant changes in the benefits.

Some of the problems may be a result of insurers not understanding the federal requirements.

If a doctor gives a woman a pregnancy test because she or he wants to make sure the patient isn't pregnant before a birth control device like an IUD is inserted, federal officials say that plans should cover it.

"Our guidance says that services related to follow-up and management of side effects, counseling for continued adherence, and for device removal are included in the scope of required services," said Alicia Hartinger, a spokeswoman for the Centers for Medicare and Medicaid Services, which is implementing the law. "We expect plans to make a reasonable, good-faith interpretation of our guidance. We believe that this includes the services necessary for the safe and effective use of a medical device—such as a pregnancy test—as determined by a woman's physician, as part of the patient's medical management."

But in other cases, insurers may be justified in charging copays. If the primary reason someone goes to doctor is for a medical concern that is not related to birth control or other preventive care, then insurance companies can charge copays, even if a doctor discusses birth control with a patient. If a patient gets a preventive service from a medical provider that is out of the plan's network, then the plan can charge copays, Hartinger said.

And one particularly murky part of the requirement allows plans to exercise "reasonable medical management."

"It's pretty unclear even to me what that means exactly," said Judy Waxman, vice president for health and reproductive rights at the National Women's Law Center; she is an expert on the law and is overseeing the group's efforts to check for problems. "The federal guidance says they have to cover all methods but don't have to cover every single brand and every single thing on the market. That gets confusing to everyone."

Most experts agree that under the exception, insurers have to cover a variety of types of birth control, including sterilization, IUDs with or without hormones, injections, pills, a patch, rings, diaphragms, sponges and cervical caps with spermicide. They also agree that insurers can require patients to get generics or particular brand-name drugs rather than other brand-name drugs.

However, patients who have difficulty getting insurers to cover a particular type of birth control pill are still supposed to be able to get it without having to pay copays if a doctor says it's necessary for a medical reason.

Beyond that, the interpretation of what the preventive care requirement includes is still evolving, particularly given that the benefit is relatively new.

"Plans are working very hard to implement this provision properly but the other issue is sometimes new circumstances come up that haven't been thought of before," said Pisano. "When that happens, we seek guidance about it. It's the plans' intention to implement it properly."

Waxman agreed that in the future, any glitches will get worked out as people learn more about the details of the law.

"Over time, more people will know and a lot of companies will get it together," she said.

The women's groups are doing all they can to raise awareness of the benefits so that the law can be implemented as intended.

"How many women know about this?" said Waxman. "Let's face it: Half the women don't know the law passed, let alone know that you can get your birth control without a copay."

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