Managing Your Practice

As the Affordable Care Act comes of age, a look behind the headlines

OBG Manag. 2014 January;26(1):40-47
By
Lucia DiVenere, MA
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Know the facts behind the accusations and counter-claims so you can point your patients toward cost-effective coverage
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As ICD-10 conversion nears, Dr. Barbara Levy advises you keep these factors in mind to ensure proper reimbursements in 2014


 

The Affordable Care Act (ACA) faced—and failed—an important test on October 1, 2013, when open enrollment began in the new health-care marketplaces. Plenty has been written about Web site crashes, technical glitches, and what seems to be general mismanagement of this crucial aspect of implementation.

Let’s look behind the headlines to see which aspects of the ACA are working, and which aren’t, and why.

KNOWING THE FACTS CAN HELP YOU HELP YOUR PATIENTS
ObGyns are scientists. As a scientist, you know the importance of facts. In your research and clinical care, you seek out and rely on scientific facts and evidence. You leave aside unsubstantiated thinking.

It’s imperative that we take the same approach with this subject. Far too many misleading and unsubstantiated claims and headlines are crowding out reliable factual information, seriously hindering physicians’ ability to understand this important health-care system change and respond to it appropriately on behalf of patients. As much as we all love Facebook, for example, it may not be the most accurate source of information on the ACA.

Plenty of reliable, factual, unbiased sources of information about the ACA exist, such as “Understanding Obamacare, Politico’s Guide to the Affordable Care Act” (http://www.politico.com/obamacare-guide/). Other helpful sources of ACA outreach and enrollment information:

A REVIEW OF THE CHANGES UNDER ACA
Let’s start with one key fact: The ACA offers a lot of good for women’s health care. Many of these improvements hinge on individuals’ ability to enroll in private health insurance policies sold in the marketplaces.

Each state’s marketplace is similar to the system used by the Federal Employees Health Benefits Program (FEHBP), the insurance marketplace used nationwide by federal employees, including members of Congress. Private plans, such as Blue Cross Blue Shield, Aetna, and United Healthcare, offer health insurance on the FEHBP marketplace to the millions of federal employees each year.

In state marketplaces, private health insurers will offer plans to potentially millions of previously under- or uninsured individuals and families. In exchange for access to this huge new group of consumers, private insurers must abide by a number of important consumer protections in order to be eligible to sell their policies in a state marketplace:

  • Insurers must agree to abide by the 80/20 rule. Under this game-changer, insurers agree to return the actuarial value of 80% of an enrollee’s premium to health care, keeping only a maximum of 20% for profits and other non-health-care categories.

  • Insurers must agree to cover 10 essential benefits, including maternity care.

  • Insurers must agree to cover key preventive services, without copays or deductibles, helping our patients stay healthy.

  • Insurers must abide by significant insurance protections. They can’t, for example, deny a woman coverage because she has a preexisting condition, was once the victim of domestic violence, or once had a cesarean delivery.

Essential benefits and preventive services
All private health insurance plans sold in the state marketplaces must cover the 10 essential health benefits:

  • ambulatory patient services

  • emergency services

  • hospitalization

  • maternity and newborn care

  • mental health and substance use disorder services, including behavioral health treatment

  • prescription drugs

  • rehabilitative and habilitative services and devices

  • laboratory services

  • preventive and wellness services and chronic disease management

  • pediatric services, including oral and vision care.

These insurers also must cover—with no charge to the patient—preventive services:

  • well-woman visits (one or more)

  • all FDA-approved contraceptive methods and contraception counseling

  • gestational diabetes screening

  • mammograms

  • Pap tests

  • HIV and other sexually transmitted infection screening and counseling

  • breastfeeding support, supplies, and counseling

  • domestic violence screening and counseling.

Related Article: Your age-based guide to comprehensive well-woman care Robert L. Barbieri, MD (October 2012)

In addition, private insurers must offer additional preventive services, although they can charge copays for them:

  • anemia screening on a routine basis for pregnant women

  • screening for urinary tract or other infection for pregnant women

  • counseling about genetic testing for a BRCA mutation for women at higher risk

  • counseling about chemoprevention of breast cancer for women at higher risk

  • cervical cancer screening for sexually active women

  • folic acid supplementation for women who may become pregnant

  • osteoporosis screening for women over age 60, depending on risk factors

  • screening for Rh incompatibility for all pregnant women and follow-up testing for women at higher risk

  • tobacco use screening and interventions for all women, and expanded counseling for pregnant users of tobacco.

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