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Fully covered mammogram screenings are part of Obamacare

Published Oct. 3, 2013

With Breast Cancer Awareness Month and the Affordable Care Act marketplaces getting under way this week, it's a good time to share an email from a reader touching on both topics.

At my well woman appointment yesterday, I was informed under the new law I would be allowed to have a mammogram every three years. . . . I am hoping that the change our President talked about is not this!

I'm happy to report that triennial mammograms are not a feature of the health care law. All plans sold on the marketplace — and many others — must cover screening mammograms for women over 40 every one to two years without charging a copayment or coinsurance. That's the case even if you haven't met your yearly deductible. This is especially important if, like many of us, you must accept big deductibles in order to afford your premiums.

Marketplace insurance plans also must cover genetic counseling and chemoprevention counseling for women at higher risk for breast cancer, as well as annual well-woman visit for women in all risk categories. Again, no copay or coinsurance.

I called Lynne Hildreth, department administrator at the Center for Women's Oncology and Cancer Screening and Prevention at Moffitt Cancer Center, to find out what she's seeing regarding insurance and mammograms.

The confusion she encounters most often involves the distinction between screening and diagnostic mammograms. Diagnostic mammograms — the test doctors prescribe when a problem is suspected — are billed like any medical procedure, not under the screening rules. This means diagnostic scans are covered (and probably not at 100 percent) only after you hit your deductible.

So look at your doctor's mammogram prescription, and if it says it's a diagnostic test, make sure you understand why. (No, this screening vs. diagnostic business is not an Obamacare innovation — I bumped up against it myself a couple years ago.)

Mammogram rules are the easy part of the email to answer. The harder question is this:

How do you know if your doctor's office knows what they're talking about when they talk about insurance?

I run into conflicts all the time between my insurer and my doctors. It is annoying and frustrating and potentially expensive.

To keep my blood pressure down, I try also to see it as interesting. Sometimes the doctor's office is right, sometimes the insurer is. It's always a surprise.

I think of insurance as a foreign country with a language and customs all its own. You need to know if the provider is in network, or out of network. Preferred or participating provider? What's your deductible? Your coinsurance? Copayment? Preauthorization?

"There are so many nuances to this,'' Hildreth said.

That's the truth.

But given how many people were jamming the Internet and phone lines this week to sign up for insurance in the Affordable Care Act marketplaces, it's clear plenty of us would rather be periodically annoyed than perpetually uninsured.

Whatever you do, don't let the mysteries of insurance — and the many misconceptions we all keep hearing — keep you from getting the care you need. You may have to ask a lot of questions. You might encounter people who try to make you feel stupid, and you might also meet those who work hard to help you.

But your good health is up to you, and it's worth your effort.

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