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Why is it called health Insurance if you have to be sick to use it?

While the common term is “Health Insurance”…it is really “Sickness” Insurance”.  If you rarely see a doctor, except for an annual preventive exam, you typically end up paying most of the bill. This leaves many healthy individuals in an uproar about paying their premiums.  If “nothing is covered”, in their eyes, because they are never sick, then why even have insurance, particularly if it’s a PPO.  (Preferred Provider Organization). Few understand the importance of insurance until it is too late. Co-pays and other out-of-pocket costs to help prevent health problems were a stumbling block for many people. For example, 12% of children have not had a doctor's visit within the last year for their annual checkup. And of those children who have, only half have received recommended care.

Many lawmakers in Congress began to understand that if people had preventive care covered many would be more likely to stay up on their health and insurance, rather than waiting until they became ill and incurred expensive hospital bills. It’s a simple concept that took some time to enact.

Under the new Health Reform legislation, if you enroll(ed) in a new health plan on or after Sept. 23, 2010, the plan must provide age and gender recommended preventive care services without cost-sharing , such as co-pays, co-insurance  or deductibles.

The new regulations represent a fundamental shift in how health care is addressed. Over time, between today and 2013, the new preventive care provisions will help an estimated 88 million Americans get preventive care, including those in both group and individual plans, according to government estimates. Under many large employer plans, these services have been covered for some time

Q: Do all health plans have to provide free preventive care?

A: No. Insurance plans that were already in place when health reform became law on March 23, 2010, are considered grandfathered and won't be required to comply with a number of provisions of the new law.

However, the expectation is that most health plans will lose their grandfathered status due to significant changes in their benefit design by 2014 and be required to comply with all aspects of the new law.

Q: Can we count on free preventive care, or is everything in limbo?

A: Ever since the Affordable Care Act was passed in March 2010, there has been much talk about repealing the law -- and in January 2011, the House of Representatives voted to repeal the Affordable Care Act. That has many Americans confused, believing that the health care reform law was overturned and that access to free preventive care, among other benefits, has been lost.

Nothing could be further from the truth. The law is still in place, because the Senate was not successful in their bid for repeal.

While lawmakers can hold up money for aspects of the law that have yet to be implemented, repealing the entire law or even specific consumer protections, such as preventive care, are not likely.

Q: Are there any situations in which I might be charged for a wellness (preventive) visit?

A: Yes. It’s important that you understand your specific benefit plan and the rules you must follow in order to have your care paid for.

In addition, you must see your doctor for the specific purpose of ‘preventive care’ in order to have the visit paid for in full. If you require a screening or blood test during your Drs. visit due to medical reasons other than prevention, you will likely have to share in some of the cost.

Some Important Details

  • This preventive services provision applies to people enrolled in either group or individual health insurance policies created after March 23, 2010. If you are in a health plan effective after March 23, 2010, this provision will apply as soon as your plan begins its first new “plan year” or “policy year” on or after September 23, 2010.
  • If your plan is “grandfathered,” these benefits may not be available to you.
  • If your health plan is a PPO that requires you to use network providers, be aware that it is not obligated to provide these preventive services for out of network providers. Your health plan may allow you to receive these services from an out-of-network provider, but may charge you a fee.
  • Your doctor may provide a preventive service, such as a cholesterol screening test, as part of an office visit. Be aware that your plan may require you to pay some costs of the office visit, if the preventive service is not the primary purpose of the visit, or if your doctor bills you for the preventive services separately from the office visit.
  • If you have questions about whether these new provisions apply to your plan, contact your insurer or plan administrator.  If you still have questions, contact your State insurance department.
  • To know which covered preventive services are right for you—based on your age, gender, and health status—ask your health care provider.

I encourage you to be proactive about your health care. Ask questions when you’re in the doctor’s office. Read your policy E.O.C (Explanation of Coverage). The more you know and are aware, the less likely you will be left in the dark.

Helpful links:

Healthy Men

Healthy Women

Jolene Bibian, RP

Registered ParaplannerSM

Ca Ins Lic # 0E33032

Leon Rousso & Associates