THCB

Does the ACA Actually Mandate Free Checkups?

flying cadeucii“Where in the Affordable Care Act (ACA) does it mandate that every health insurance policy must include a free annual checkup?”

I posed this question to Al Lewis and Vik Khanna in the comments of their recent post entitled: The High Cost of Free Checkups, where they argue against the Affordable Care Act (ACA) provision that requires “free checkups for everyone.” They cite a recent New York Times Op-ed authored by ACA co-architect, Dr. Ezekiel Emanuel, that essentially debunks the link between annual checkups and overall health outcomes.  For Lewis and Khanna the solution is simple, we need to “remove the ACA provision that makes annual checkups automatically immune from deductibles and copays.” But for me there’s an enormous problem with their argument: The ACA doesn’t actually have any such provision.

After raising the issue in the comments section of the post, Mr. Lewis responded informing me that: “It’s definitely there” and “You’ll have to find it on your own, though — I unfortunately have to get back to my day job.” What Mr. Lewis doesn’t consider with his quick dismissal, is that I have already looked.  I’ve combed through the law and other policy guidance, rules and regs; searching for any mention of this required annual wellness exam, physical, visit, or any other linguistic derivative.  It doesn’t exist.

It turns out that while the law does require that an annual wellness visit be covered (sec. 4103. “Medicare coverage of annual wellness visit providing a personalized prevention plan”), this requirement is specific to Medicare beneficiaries and does not apply to individual or group plans. Beyond this particular section you won’t find any mention of a requirement within the ACA.

So what gives?  Lewis and Khanna aren’t the only ones who’ve mentioned this “free” Obamacare benefit. Even when researching this piece I had to engage in a lengthy discussion with a friend who is a healthcare policy advisor, unexpectedly defending my position. This claim has to be coming from somewhere, surely people smarter than me have gotten it right?

I suspect the confusion stems from the fact that the ACA makes preventive services free for virtually everyone.  But that’s not the same thing as saying everyone is entitled to a free annual checkup.  When you read sec. 2713. “Coverage of preventive health services” of the ACA, it basically says that in the Individual and Group markets, at a minimum, insurers must provide coverage (meaning they must pay 100% of the cost) for certain preventive benefits and services.  It goes on to state that those services are defined as “evidence-based items or services that have in effect a rating of ‘A’ or ‘B’ in the current recommendations of the United States Preventive Services Task Force;”

In other words, outside of a few mandated preventive services (such as visits for women and children only), the law leaves it up to this independent task force to determine what preventive services should be covered for free.  Several of these services aren’t available every year and in the aggregate, they don’t necessarily comprise all the services typically included in the annual wellness exam. As Dr. Emanuel points out in his Op-ed, the lack of evidence that annual checkups lead to healthier outcomes is the main reason that same task force “does NOT have a recommendation on routine annual health checkups.”

Propelled by a derisive political debate primarily concerned with the promotion or denigration of this new healthcare law, somewhere along the way we’ve gotten it twisted. And while I wouldn’t normally care, navigating the truths of the industry is complex enough.  It get’s that much more difficult when those truths are littered with negligent misinformation.

So, I’d like to take this opportunity to once again ask Mr. Lewis or Mr. Khanna: “Where in the ACA does it require insurance companies to provide a free annual checkup for everyone?” As a longtime reader of this blog I’ve always appreciated the provocative content, discussions, and thought leadership inspired herein; but I’ve never actually written anything.  In this case, I just felt strongly about correcting the record, because understanding the ACA doesn’t have to be your day job to care about the veracity of what you write.

Christian Gleason is a healthcare marketplace analyst with GetInsured.com

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carl75KenNoteJ. Kirschman, MDWilliam Palmer MDAllan Recent comment authors
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carl75
Member
carl75

At the most granular level, I pose this question: Did the ACA literally outline a definition of preventative services that are covered at the CPT level? If not, has such a list been codified by consensus amongst providers and insurers? If I have a high deductible plan as a consumer, I should literally be able to know what I expect to pay for. Of course, the average consumer does not concern themselves with the intricacies of medical coding, but SOMEONE, ANYONE should be able to answer this question. If not, then the fucking bill needs to be clarified.

KenNote
Member
KenNote

Thanks for share. http://note.taable.com/

J. Kirschman, MD
Guest
J. Kirschman, MD

There is commonality between the Supreme Court case and the blog post — both rest on the definitions of words being used and the intent. In the blog post, words such as screening, check-up, and physical examination are all used, though never defined, as they were never defined nor mentioned in the ACA. To the lay person, most do not see the difference between a check-up, a physical examination, a screening or a preventive benefit. Having performed Medicare Wellness visits in the past, I am well aware that those patients thought they were going to get something entirely different from… Read more »

Tom Emerick
Guest
Tom Emerick

When a conversation devolves into accusing those with whom you disagree of abetting National Socialism, count me out.

Al Lewis
Guest
Al Lewis

We have placed a public apology both for being wrong (though there is some ambiguity– the shots are free, the screens are free, as part of a checkup) AND for being snitty about it — on http://theysaidwhat.net/2015/03/10/stop-the-presses-we-goofed/

This is literally the first time we have ever been wrong (though it doesn’t change the answer, which is that companies need to stop attaching more money to these things) and I’d like to think we are setting an example for Ron Goetzel and his wellness cabal but owning up.

Tazia K. Stagg
Guest
Tazia K. Stagg

“I don’t know what [that] is supposed to be!”

Allan
Guest
Allan

Did the ACA say everyone has a free wellness exam in exactly those words? No. But at http://www.hhs.gov/healthcare/facts/factsheets/2010/07/preventive-services-list.html#CoveredPreventiveServicesforAdults we see the following… “the following preventive services must be covered without your having to pay a copayment or co-insurance or meet your deductible. This applies only when these services are delivered by a network provider. ” Some of you guys are like concrete, and have difficulty seeing the forest for the trees. What are those services? Blood pressure screening for all adults. If a network provider provides that service is that not a portion of the wellness exam? How about the… Read more »

Tazia K. Stagg
Guest
Tazia K. Stagg

Preventive services are often provided opportunistically (in the course of a visit that’s primarily for something else).

Allan
Guest
Allan

They might be, but they don’t have to be. Some people might not visit a doctor for years.In any event the physician should be paid extra for managing and evaluating things that another might call a preventative service so I am not sure of your point.

Let me go further. Just because Medicare offers wellness visits and pays for the visit doesn’t mean the physician will want to use that code number treating a patient.

Too much top down garbage that creates confusion, increased cost and eventually impacts quality and access.

Tazia K. Stagg
Guest
Tazia K. Stagg

I’m sorry. I was responding to: “If a network provider provides that service is that not a portion of the wellness exam?”

Christian
Guest
Christian

The issue with the traditional annual physical is that data has shown it doesn’t necessarily lead to better health outcomes. Thus most of Al and Vik’s argument about the “High Cost” of the free annual checkups. The list of preventive services you reference the ACA mandates be covered, are specific preventive services an independent task force has identified as having a strong impact on health outcomes. Once that link has been established, unless you disprove the taskforce’s evidence, I’m just not sure how the argument still stand. This is why they’re not the same thing. Furthermore, from the consumer perspective,… Read more »

@BobbyGvegas
Guest

From Vik’s book: “Hospitals are happily lapping up the supply of newly insured Americans and shoving them through their overbuilt capacity of scanners and blood testers to find incipient problems for which they can render even more services. Thus, while the service was “free” to you, the hospital still billed the health plan for it. More people = more billings = more revenue for hospitals and health systems and, in turn, more claims submitted to health plans. This will cause health plans to complain and reapply themselves to the process of limiting other forms of care through administrative hurdles, narrow… Read more »

Tazia K. Stagg
Guest
Tazia K. Stagg

hahahahaha
Thank you

J. Kirschman MD
Guest
J. Kirschman MD

I find it interesting that the website that Mr. Glason works for has the following posted on their website regarding free annual exams (https://www.getinsured.com/answers/expert-answers/what-kind-of-medical-services-does-my-plan-offer-for-free/): “Q: What kind of medical services does my plan offer for free? Answered by : Sean WoodsAugust 29, 2014 The Affordable Care Act (ACA) has a rule that qualified health insurance plans sold on healthcare.gov, state-based marketplaces, or through a certified Web broker must include 10 essential health benefits. One of these benefits is preventive care, such as some annual checkups, physicals, and screenings. None of these are subject to any kind of health insurance expenses,… Read more »

Tazia K. Stagg
Guest
Tazia K. Stagg

Maybe HE’S the friend Christian told us about!!!

Christian
Guest
Christian

I appreciate the reply as I truly believe this is worthy of a discussion. Also, thanks for getting my name correct :). You’ll notice the copy says, “some annual checkups” but not “all annual checkups.” This was intentional as it’s been difficult to get a black and white answer on this. It’s the whole reason I wrote the post. One of the preventive services that’s listed on healthcare.gov SPECIFICALLY for women is: “Well-woman visits to get recommended services for women under 65.” This is a separate line item from all the other preventive services listed for women and adults. You… Read more »

Tom Emerick
Guest
Tom Emerick

I read the ACA with amendments cover to cover. It does seem to imply coverage for an annual check up, which is sometimes called the annual wellness exam.

For certain the ACA has an abundance of ambiguity.

Cheers,

Tom

@BobbyGvegas
Guest

BTW: Wearables update, the release of the iWatch, or, as I call it, the iWatch YOU®

http://regionalextensioncenter.blogspot.com/2015/03/wearables-update-iwatch.html

Karen Engberg, MD
Guest

HMOs are the answer. The ACA provision covers a small range of preventive services that are known to make a difference in health care outcomes. However, this has been pitched to the consumer/voter as an entitlement to free annual check-ups, an assumption that is the bane of every primary care provider’s billing office. The idea behind the provision is to catch things early and thereby, theoretically, provide treatment that is both more likely to be effective and cost less in the long term. The problem is that medical care doesn’t parce nicely along such lines. To wit: A perfectly healthy… Read more »

Tazia K. Stagg
Guest
Tazia K. Stagg

What problem do HMOs answer?

Tazia K. Stagg
Guest
Tazia K. Stagg

Al and Vik, where did you get the misinformation?

Al Lewis
Guest
Al Lewis

I think it’s a benefits consulting urban legend. We made the assumption they knew what they were talking about — it’s not true in wellness (Mercer in particular has been caught in several lies) but we assumed that since they get paid to implement ACA, that they knew the first thing about ACA.

“I made a mistake. I trusted the experts,”
–John F. Kennedy

Tazia K. Stagg
Guest
Tazia K. Stagg

Using that quotation doesn’t help your credibility.

Peter1
Guest
Peter1

Thanks Mr. Galson for posting this.

Can’t understand why Vik and Al can’t just say “we were wrong”, instead of attempting to promote their “wellness checkups don’t work” mantra to obfuscate their error.

Tom Emerick
Guest
Tom Emerick

Peter1, as you’ve read in the posts here it is easy for people goodwill to differ on interpreting ACA mandates. I do not believe Al and Vik have anything to apologize for unless it is for interpreting an ACA ambiguity.

Tom

Tazia K. Stagg
Guest
Tazia K. Stagg

This was a demonstration of quality of information and then of character. It did not involve an ACA ambiguity.

Tom Emerick
Guest
Tom Emerick

Tazia,

I respectfully disagree. I personally saw the ambiguity myself when I read the ACA bill in its entirety

tom

Tom Emerick
Guest
Tom Emerick

please correct me if I misunderstood your comment.

tom

Tazia K. Stagg
Guest
Tazia K. Stagg

I can’t tell why you disagree.

Tom Emerick
Guest
Tom Emerick

ACA is riddled with ambiguity.

tom

Peter1
Guest
Peter1

“I do not believe Al and Vik have anything to apologize for unless it is for interpreting an ACA ambiguity.” Tom, Al lewis states: “and do we not claim to be experts of ACA rule-making, just on the implications of those rules” The two ends of that statement don’t connect. If they aren’t “experts” on one how can they be experts on the other? Vik offers: “While Mr. Gleason is technically correct that the ACA does not specifically and explicitly confer covered status upon annual physicals” So nowhere in their promotion that the ACA does mandate free checkups is there… Read more »

Al Lewis
Guest
Al Lewis

Thanks, Tom but we did apologize,publicly, on our website, just the same. We are not wrong about the proposed action — that is the same — just about the misinterpretation. Now I’d like to see Mercer, AonHewitt and all those others who have told large employers the exact same thing we just said (we got our info from them) that despite their huge fees and not knowing anything about wellness, it turns out they don’t know anything about ACA either

Tazia K. Stagg
Guest
Tazia K. Stagg

Who does know anything about wellness?

Al Lewis
Guest
Al Lewis

see http://www.theysaidwhat.net — you’ll see a lot about wellness. Obviously it is right or we would have been sued by now

Tazia K. Stagg
Guest
Tazia K. Stagg

What do you say you’re trying to accomplish?

Retired MD
Guest
Retired MD

If one looks at the Wellness rules attached to the ACA, http://www.dol.gov/ebsa/pdf/workplacewellnessstudyfinalrule.pdf, and you go to page 6, you will see that for these programs the wellness visit; “1. The program must give eligible individuals an opportunity to qualify for the reward at
least once per year.” This is essentially the same type of evaluation as the Wellness visit for Medicare. There are more “clarifications” in the final rule. But in essence it requires the individual to go yearly to be able to obtain a discount on their premium. While not mandatory, it is coercive.

David Napoli
Guest
David Napoli

This article misses the obvious – the AV calculator

Tazia K. Stagg
Guest
Tazia K. Stagg

Please elaborate.

Perry
Guest
Perry
Tazia K. Stagg
Guest
Tazia K. Stagg

Thank you. I still agree with the article (except for Dr. Emanuel’s misunderstanding) and wonder why David thought this was “the obvious” and missing.