A new age in health care
When Chet Waldhart turned 50, his doctor recommended he get a colonoscopy.
A couple days before his appointment, the nurse called to say his insurance wouldn't cover the procedure because it was deemed "routine."
If he'd gotten the colonoscopy more than four years ago, he might not be receiving chemotherapy at least once a month for his stage IV colon cancer.
Recent changes spurred by federal health care reform now require insurance coverage for preventive cancer screening, Waldhart said. He wants people to be aware that things have changed.
"Prevention is a lot better than trying to take care of the problem afterward," said Waldhart, who works in airport maintenance at the Southern Wisconsin Regional Airport.
His insurance covered the cancer screening after he started showing symptoms. In March 2009, he was diagnosed with cancer that will never go away—"the best I can hope for is to get into remission," he said.
Waldhart of Janesville said he'll benefit from many of the health care reform changes already in place.
In September, a small slice of the giant federal Affordable Care Act went into effect, six months after President Barack Obama signed the reform into law. It's only the start of changes that will continue through 2014.
Most people haven't yet seen changes apply to them because their insurance plans haven't renewed, said Lisa Tranberg, director of marketing and product innovations for Dean Health Plan.
Keep in mind, nothing is simple when the law is 2,700 pages. If the changes below sound simple, remember each insurance plan is different and factors such as age play a role in what applies. Tranberg explained some of the major changes in place:
-- Removal of policy limits. A plan could no longer enforce a $2 million lifetime limit, she said.
-- More preventive services are covered. If the Centers for Disease Control recommends a screening or service, plans must pay for those recommended screenings at no cost to the member, she said.
The tricky part, she said, is determining what is preventive versus routine. She said the government is doing a nice job of explaining changes at healthcare.gov. The site lists blood pressure, diabetes and cholesterol tests as well as many cancer screenings—including mammograms and colonoscopies—as preventive services that you may have free access to, depending on your age.
-- More coverage for children and young adults. Insurers can no longer deny coverage or put limits on coverage for individuals under the age of 19 for preexisting conditions. Plans that cover dependents must allow parents to add coverage of children up to age 26, as long as the adult child does not qualify for coverage from his or her employer.
-- Emergency services need to be paid at the same cost whether the treatment was in or out of network.
Get ready to take a number at your human resources department.
But that's what health officials advise.
"Spend some time with (your) HR benefit representatives," said Rich Gruber, a vice president at Mercy Health System. "Be proactive as a consumer.
"What we're hearing more than anything else is, ‘What are the changes, and how are they going to affect me as an individual?'" he said.
The challenge for every organization will be to realize what changes apply and then begin the huge education process, he said.
Rolling out the first limited set of changes has gone smoother than expected, Tranberg said.
But with Republicans in Washington talking about repealing or changing the reform, another variable is added.
"From our perspective, that creates a great amount of uncertainty getting through the next big wave of reform," Tranberg said.
Consumers need to be even more engaged in their health care to understand what changes apply to them, she said. The continued and unprecedented changes "will put pressure on all constituents and all stakeholders to get more involved," she said.
For Waldhart, his message remains clear: If your doctor recommends a colonoscopy or other preventive screening, do it.
"Because you never know," he said.
Last updated: 3:35 pm Thursday, December 13, 2012