Max OOP doesn’t like getting ordered around. It is one of the reasons I got interested in early retirement in the first place. No boss, no orders. But since we like to make healthcare complicated, I guess I will need to make exceptions from time to time.
One big reason I scheduled my free preventive health physical exam was to get orders; lab orders. A lab order from a doctor or qualified medical provider is required by most laboratories before they can move forward with a lab test. In other words, if I show up to a lab and ask for a specific test, they are going to look at me funny, then tell me to go see my doctor first. No order, no lab test.
Lab tests are nice because you get to look at what is going on inside your body. One of the labs I have become interested in as I have rolled into my mid-30s is the cholesterol test. I don’t like the idea of waxy substances floating around my blood getting stuck to things. This could cause some problems for me later in life and have a serious impact on my early retirement plans.
So I will go ahead and ask my doctor to order a cholesterol screening at my free annual preventive healthcare exam in October. He probably would order it anyway since it has become pretty standard in the annual checkup for someone in my age bucket. He will order what the coding world would call a lipid panel. This falls under CPT code 80061 for all you coding experts out there. For everyone else, don’t worry, Max OOP will have you talking circles around billing departments in no time.
A lipid panel measures cholesterol, triglycerides, HDL cholesterol, and LDL cholesterol.
But how do we get it for free?
Affordable Care Act
The Affordable Care Act (ACA) made a lot of changes to the healthcare world. Today we are just going to talk about one of those changes; mandated coverage of the cholesterol screening with no out-of-pocket costs to the patient.
The Affordable Care Act mandates private health plans to provide coverage for a wide range of preventive services. One of these services is the cholesterol screening. This assumes, of course, that certain criteria are met.
The ACA applied the mandate to all private plans except for the plans in ‘grandfathered’ status. Grandfathered plans are basically exempt from a lot of the ACA requirements. Max OOP will venture a guess that even most of these grandfathered plans probably even pay for the cholesterol screening with no out-of-pocket cost to the patient. Since I meet the criteria below, my cholesterol lipid screening lab test should be free even though I am on a high deductible plan. Since mine is a true screening, I will make sure my lipid panel is ordered by my medical provider with diagnosis code Z00.00 (Encounter for general adult medical examination without abnormal findings) since this is what will trigger my insurance to waive my out of pocket costs on the test.
Believe it or not, the law entitles a pretty large portion of the population to this free preventive cholesterol screening with no out-of-pocket costs. There are, however, some age requirements and risk profiles to look at before we can lawyer up and sue an insurance company when they try to have us billed for the lipid panel.
In my experience, since the Affordable Care Act made this so confusing, a lot of insurance companies take the conservative approach and just cover this screening for everyone. That way, they don’t risk accidentally breaking the law.
You can find the cholesterol screening on the preventive list over at healthcare.gov, but you won’t find the cholesterol screening anywhere in the actual Affordable Care Act.
It’s The Law
The Affordable Care Act amended and added a section to the Public Health Service Act. One of the sections Max is interested in is 2713. Feel free to bust this law out on your insurance company or billing department if you ever need it.
‘SEC. 2713. COVERAGE OF PREVENTIVE HEALTH SERVICES. ‘‘(a) IN GENERAL.—A group health plan and a health insurance issuer offering group or individual health insurance coverage shall, at a minimum provide coverage for and shall not impose any cost sharing requirements for— ‘‘(1) 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…Link to the law.
The required cholesterol screening comes from recommendations made by an expert scientific body called the United States Preventive Services Task Force (USPSTF)
Since the government and the Affordable Care Act are far from experts on preventive care, they turn to an organization that actually studies this stuff. The designated expert in this field is the United States Preventive Task Force. They have determined that if we meet the following parameters, there is a material benefit to having the cholesterol test. The ACA, in turn, mandated the patient out-of-pocket cost on the screening tests should be waived.
So as you can see, any men aged 35 and older are entitled to a cholesterol screening regardless of their risk profile. Women, on the other hand, are only entitled to it if they are at an increased risk. Finally, a benefit that men get that women don’t. Obviously joking, but I didn’t make the rules, it’s evidence-based. Increased risk? That is for the patient and doctor to figure out, not Max. I’m just a bean counter.
A scientific body took the time to study it and after those studies made the recommendation that any man 35 and up should get this done. The government took that recommendation and made a law that says it must be free. See how that works? Not exactly a death panel.
Unfortunately, we still somehow managed to complicate coverage of the cholesterol screening and we don’t always know exactly how our insurance company is applying these laws and recommendations.
What If I Already Have High Cholesterol? How Many Free Tests Am I Allowed Per Lifetime?
Once we already know we have high cholesterol, are future tests still considered a screening? Can I get more than one screening per year? This is where we don’t get much clarity from the Affordable Care Act or the United States Preventive Task Force. So we need to push on our insurance company to get their policy on cholesterol screening coverage. In fact, federal regulations leave it up to private insurance plans to use reasonable medical management techniques to decide several things surrounding preventive health. This can include the frequency, method, treatment, or setting for a preventive item or service if it is not specifically referenced in the guidance and recommendations.
Keep It Simple, Stupid
As mentioned above, The Affordable Care Act mandated that evidence-based items or services that have in effect a rating of “A” of “B” in the current recommendations of the United States Preventive Task Force should have the cost-share (think deductible) waived. Since the cholesterol test referenced above both have a grade of A & B, the law thus requires the out-of-pocket costs to be waived if we fit into the age and risk parameters listed above.
Here is the actual definition of each grade:
The archived final recommendation statement from the USPSTF says that men 35 and older should get screened for high cholesterol and other lipid disorders. There is a high certainty that the net benefit of us all doing this would be substantial. But it does not give any guidance on how many we get or if we still get them free once an elevated reading is determined. It goes onto say that if men are 20-35 and increased risk for coronary heart disease, we should also get a screening. But how many tests do we get? It also says only high-risk women should get screened under certain circumstances where men should be screened regardless after they hit 35. But how many? These scenarios are where those reasonable management techniques kick in and the insurance company gets to make some decisions about things like frequency and even method of testing. This doesn’t mean we can’t get one, we just might have to pay for it out-of-pocket.
Insurance companies find all this confusing, so they often opt to just cover a true screening in full for everyone regardless of age once per year. The insurance company should have a policy on this so we can clearly understand what we are getting into before we have the test.
What About Max OOP’s Insurance?
Of course, leave it to Max OOP to put some pressure on my own insurance for some direction on this very topic. I messaged them and asked about my free cholesterol test and they provided a pretty clear answer.
Although I am a little disappointed they didn’t produce an actual policy, my interpretation of the message below is I am entitled to a preventive cholesterol screening test every single year once I hit 35. That said, if my provider is using it to diagnose or treat a medical condition (such as elevated cholesterol), it would no longer meet the definition of a preventive screening. At that point, I am paying out-of-pocket and it will hit my deductible.
If you really want to run circles around a billing office or insurance plans when talking about the cholesterol screening, bust out the Affordable Care Act, Public Health Service Act, and the US Preventive Task Force. If you think you fit into the parameters above, don’t be afraid to push back if you are getting billed in error. Normally, it is ideal for the claim to be submitted with a diagnosis code of Z00.00 (Encounter for general adult medical examination without abnormal findings). That’s because a lot of insurance companies set their system to waive the out-of-pocket costs on the lipid panel when billed for this diagnosis code. As always, check with your insurance to be sure.
I personally think we should all be looking into cholesterol screening options with our doctor to see if it is something we should be monitoring and how often. Since the Affordable Care Act and the United States Preventive Task Force think this test is a good idea to look at this, that’s good enough for me. Who knows, if we meet the age/risk parameters outlined above, pretty good chance it will be free anyway.
It is my opinion that insurance companies should just concede and offer this test free for everyone age 35 and up regardless of risk, sex, and historical cholesterol readings. How often? I don’t know, that’s not my wheelhouse. I just want it to be clear so we don’t get surprise bills. It would be an easier benefit to understand and reduce questions and calls to insurance and billing call centers if they just covered one lipid panel at a certain frequency for their entire insured population. Going above and beyond the USPSTF recommendation could also make a good marketing strategy.
Max Out of Pocket for my 2019 lipid panel = $0.00
Usual disclaimer: I am not a medical professional and this is not a recommendation to get or not get a cholesterol screening. Insurance plans may not always cover this test depending on the circumstances.