Still a little confused about the Affordable Care Act (even after reading Women’s Health‘s primer on the reform)? You’re in good company: 57 percent of Americans say they still don’t have enough information to understand how the ACA will affect them, according to a new poll by the nonprofit Kaiser Family Foundation. For the second installment in our series on the ACA, Women’s Health spoke with Mayra E. Alvarez, Director of Public Health Policy at the Office of Health Reform in the U.S. Department of Health and Human Services, to get answers to your biggest questions about the reform:
Women’s Health: How exactly do you take advantage of the free preventive services? Do you have to go to a special clinic to get them or take any other special measures?
Mayra E. Alvarez: No, not at all. This is for people that have private insurance and new plans or non-grandfathered plans. When you go to the doctor’s office, so long as the purpose of the service is preventive, it should be seamless for you to get that without a co-pay.
WH: Does that mean the ACA covers the cost of co-pays for your annual gyno exam, since you’re going strictly for preventative services?
MA: One of the services covered by the women’s preventive service guidelines (added in 2011) is your well-woman visit. It’s the idea that women need to go to the doctor to check on our health care status, so it’s an opportunity to have multiple things checked but more importantly to talk to our doctors about our health and be informed consumers. The point is really to empower women to take control of their health.
WH: If a woman goes into her OB/GYN office and is told she owes a co-pay, how can she ensure she gets that cost covered?
MA: She should check with her insurance provider to confirm what the situation was and why she was charged a co-pay. If the response from the insurer is not sufficient to her understanding of the ACA, she can check with her insurance commissioner’s office or the state agency that handles insurance administration.
WH: What kinds of birth control (if any) are covered without a co-pay under the ACA?
MA: The ACA actually covers all FDA-approved contraceptive methods. What we want to try to do in practice is ensure women have access to the services that are right for her, so this includes barrier methods, hormonal methods, and implanted devices. (Check the full list of FDA-approved methods.) The one clarifying thing you should know about: insurers are able to use reasonable medical management techniques to control their costs. So they may cover a generic drug without cost-sharing (so you wouldn’t pay anything for this), but then charge if the woman chooses to go for a brand-name drug. The only instance where that’s not the case is when a doctor prescribes a particular brand-name method based on the woman’s needs.
WH: Does that mean emergency contraception is also covered?
MA: It is, so long as it comes with a prescription from the woman’s health care provider. Right now if you’re over 17 you could technically buy it over the counter, but that’s not covered by the Act.
WH: HIV and STD screenings (for HPV, chlamydia, gonorrhea, syphillis, etc.) are covered without a co-pay. But do I still have to pay lab or blood work fees?
MA: The covered service is the screening itself. For HIV, for example, the test is covered—and that’s a blood test. Same with chlamidia and gonorrhea. The test itself is the lab work that has to get done, so that is covered. The only instance where a woman would be charged a co-pay is if, for example, you have a headache and you go to the doctor’s office for that reason, but then decide while you’re there to get an HIV test. The doctor cannot charge a co-pay for the HIV test, but he can charge you a co-pay for the visit itself since you didn’t go to the doctor for the preventive service, you went because you had a headache. There is an opportunity to educate both consumers and medical professionals more about these types of situations.
WH: Is it true that people will be penalized if they don’t have health insurance? If so, when will this go into effect, and how exactly will they be penalized?
MA: There is an individual responsibility requirement as part of the Affordable Care Act. Starting in the year 2014, what we call the “individual shared responsibility provision” requires everyone to have minimum essential health coverage. (Read more about what counts as minimum essential coverage.) And if they don’t, they do have to make a payment when they’re filing their federal income tax returns. When you file for 2014, that’s when you have to make that payment. That applies to all people of all ages, including kids. Open enrollment for the marketplaces does start this October, though, so we can all take advantage of health insurance through that. You ask many people who don’t have health insurance why they don’t have it, and it’s not because they don’t want to—it’s because it’s a confusing process, it’s expensive, and they don’t know how to navigate it.
WH: What will the penalty be for not having minimum essential coverage?
MA: The first year the penalty is $ 95, and it progressively increases as we move forward (the fee increases to $ 325 for 2015 and $ 695 for 2016). It’s important to note that in Massachusetts when they launched their health care reform—and that’s one of the best examples we can use—a lot of people were subject to a very small fine. We didn’t find people paying that fine. You found people excited to get insurance and wanting to enroll, and we hope that same thing happens here.
WH: The ACA points out that being female can be considered a pre-existing condition. How do you know if you’re being charged more by your insurance company for simply being a woman?
MA: When we’ve done analyses and looked at different research, we’ve found women were paying 150 percent more for a premium than a same-aged young man would pay. It was pretty astronomical. We expect more of the same types of surveys and analyses to be done (and that information to be included on the Health Insurance Marketplace that launches in October) so we can be informed about the market and what it looks like for women and men. The idea of this Health Insurance Marketplace is to level the playing field and do away with these unfair practices.
WH: So is there any way to know right now, before that launches, if you’re being charged more just because you’re a woman?
MA: It’s interesting because it’s got a lot to do with where you live right now, so it’s hard to say. Insurance companies can also charge more for other pre-existing conditions, like disabilities or health problems. All of these market reforms, they don’t take place until 2014. So they will go into effect on January 1, 2014, and insurance companies will no longer be able to discriminate because of these conditions.
It’s so important that not only do we do away with the gender discrimination, but the idea that we can’t turn people away because of pre-existing conditions. For women that have had breast cancer, for women who were pregnant, or women who were victims of domestic violence—these could all be considered pre-existing conditions. These were real women who were turned away from health insurance because of circumstances beyond their control. This is literally a lifeline for them.
WH: You hear about lawsuits over the ACA. Is there a possibility that it will be overturned? What would happen then?
MA: The Supreme Court made their decision in June to uphold the ACA, and we’re very excited about that opportunity because it means we can move forward with ensuring millions of people have access to health insurance. Obviously there continue to be people raising questions and we’ll continue to want to educate folks on the law as we move forward. This law is like any other law; it would have to be overturned by both houses of Congress, and the President has confirmed over and over again his commitment to the law. So onward we’re charging and ensuring that we make sure everyone has access to health insurance.
Check back on Friday for the final installment in this week’s ACA series.
photo: iStockphoto/Thinkstock
More From Women’s Health:
Your Crash Course on the Affordable Care Act
From Michelle Obama: Taking Control of Our Health
Get Social for Healthcare
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