Federal health reform brings co-pay relief
By DEBORAH STAYMAN
Thanks to national health care reform passed last year, Empire Plan enrollees will start getting a break on some co-payments.
Certain office visits, tests and immunizations considered to be “preventive care” under the federal Patient Protection and Affordable Care Act will be exempt from co-payments.
Because the Empire Plan is a fully insured plan and was subject to a collectively bargained agreement (the 2007-2011 PS&T Contract) signed before March 23, 2010, it was exempted from this change until that agreement was replaced.
Catching up
Now that PEF has a new, ratified contract, that change will occur retroactive to October 1, 2011. Claims for preventive services provided on or after that date will be reprocessed by United Health Care and the co-pays will be refunded.
Benefits that will be provided with no co-pay, include:
• Adult immunizations, given by an Empire Plan participating provider, for influenza, pneumococcal, measles, mumps, rubella, varicella (chicken pox), tetanus toxoid, human papilloma virus (HPV), meningococcal meningitis and herpes zoster (shingles). Co-pays do apply for persons ages 55-59 who receive the herpes zoster immunization, because it is only recommended for ages 60 and older; and
• Screening by a participating provider for elevated cholesterol and lipids, colorectal cancer, certain sexually transmitted diseases and HIV, tobacco use, obesity, diet and nutrition, depression, high blood pressure, diabetes in adults with high blood pressure, screening and counseling for alcohol abuse.
Down the road
Starting January 1, 2013, co-pays will no longer be charged for certain services for women, including:
• Genetic counseling and evaluation for genetic testing for BRCA gene (linked to breast and ovarian cancer);
• Mammography for breast cancer beginning at age 40;
• Pap smears for cervical cancer;
• Screening for gonorrhea, chlamydia, syphilis;
• Osteoporosis screening for those at risk (age 60 or older); and
• Counseling for those at high risk of breast cancer for chemo prevention.
Also starting in 2013, men aged 65-75 who have ever smoked will have no co-pay when screened by a participating provider for abdominal aortic aneurysm.
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