It was business as usual for Katherine Campbell. Well, for the most part. She says she was having trouble sleeping and more. “I’m having mood swings and not feeling like myself. And I’m at the age where perimenopause can start,” she told Action 9 attorney Jason Stuzenke.
She went to the doctor. She says she ran tests and ultimately agreed with them: perimenopause.
He has insurance. And she knows that the Affordable Care Act says insurance must cover all types of preventive care — including many services related to women’s health. He assumed that his care fell under his responsibility. “Then I get a $2,000 bill,” she said. “I was stunned. I would not, in a million years, have thought that a change in the normal lifecycle, anything involved, would not be considered preventive.”
As far as her health is concerned, Campbell says her doctor has increased her medications. So except for the bill, she’s sleeping better.
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His insurance — Cigna Healthcare — emailed Stojenke, saying “the law distinguishes between preventive services… and diagnostic” services. “Symptoms associated with perimenopause” may be on the “clinical” side. “Under current federal regulations, those labs are generally billed as diagnostic – not preventive.” That means you could end up with a bill “even if the goal is early identification and prevention of more serious health problems.” The company says that the situation was similar here also. Additionally, Campbell had not yet received her “deductible” amount.
Cigna’s full statement: “Preventive care is essential to protect long-term health. Under the Affordable Care Act, many preventive services are covered at no cost to the patient, including recommended women’s health services such as annual visits and mammograms. What qualifies as preventive care is defined by federal clinical guidelines, including recommendations from the U.S. Preventive Services Task Force (USPSTF) and the Health Resources and Services Administration (HRSA), which recommend women’s preventive health care. The law distinguishes between preventive services, which are provided to people without symptoms to prevent disease or detect conditions early, and diagnostic tests, which are used to direct physician-ordered tests or services to evaluate symptoms or investigate a concern, usually considered diagnostic and may involve out-of-pocket expenses.
Perimenopause and menopause are important and often misunderstood transitions that can include a wide range of physical and emotional symptoms. Cigna Healthcare is committed to helping women receive appropriate care, support and treatment, and we work with health care providers, clients and customers to improve awareness, education and access to women’s health services.
Depending on the plan design, Cigna Healthcare customers have coverage options that may include hormone therapy, pelvic floor therapy, nutritional counseling and both in-person and virtual care. Through in-network options, including specialized women’s health providers and virtual care providers like MD Live, clients can access board certified physicians who are trained to recognize and manage perimenopause and menopause symptoms, helping women receive timely care and avoid unnecessary delays.
The services Ms. Campbell received are classified as diagnostic rather than preventive. While they are covered under Ms. Campbell’s specific benefit plan, cost sharing was applied because her deductible had not yet been met.
Symptoms associated with perimenopause may require diagnostic testing to rule out other conditions, such as thyroid disease or anemia. Under current federal rules, those labs are generally billed as diagnostic — not preventive — which can result in cost sharing, even if the goal is early detection and prevention of more serious health problems. This reflects a limitation in how preventive care is defined under current federal regulations and recommendations rather than a lack of prioritization of women’s health.”
Campbell’s doctors are with Atrium. That health system emailed Jason that they are committed to helping people “by providing guidance and assistance in navigating the financial aspects of health care.”
Atrium sent Action 9 a statement, saying: “We understand that the medical billing process can be complex and sometimes frustrating for patients. While federal and state laws prevent us from discussing the details of any prospective patient’s care or billing, our commitment to helping people stay well includes providing guidance and support as they navigate the financial aspects of their health care. If patients have questions or concerns about their bill, we We encourage them to reach out to our Billing Services department directly.”
Stuzenke says:
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Yes, be proactive about your health. Don’t wait.
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But just because you’re ‘proactive’ doesn’t mean it’s ‘preventive’ care.
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Know what counts as ‘preventive’. Cigna’s website explains it well (and this applies to all insurance companies, not just them). See below.
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still not sure? Ask about your insurance ahead of time.
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You may have to ask your provider how they code this.
According to the Affordable Care Act, here’s what is considered preventive care:
annual checkup or wellness exam
This is when your primary care provider (PCP) checks all areas of your well-being—both physical and mental health. Annual checkups are covered once a year and can help detect any health concerns early, before they become major medical problems.
Well-Baby and Well-Child Appointments
These are routine health checkups for infants and children. These include weight and physical growth checks, vaccinations (if necessary), and growth assessment. These usually occur at the following ages: 1 to 7 days, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 2.5 years and annually starting at 3 years of age.
flu vaccine
Flu shots are typically covered 100% each year under most health plans. These vaccines help protect you from certain strains of the flu virus as well as reduce the number of hospitalizations.
other vaccinations
Vaccinations for chickenpox, HPV, measles, mumps, rubella, polio and some other diseases are 100% covered. These are usually given during childhood and include boosters as needed.
mammogram
Mammograms are routine X-rays of the breast tissues to check for any signs of breast cancer or other abnormalities. Mammograms are usually recommended every year starting at age 40, but they may be recommended earlier if you have certain risk factors.1
colonoscopy
This is a screening for colon and colorectal cancer. It’s usually done every 10 years starting at age 45, unless you have other risk factors.2 There are also at-home tests available to screen for colorectal cancer that are covered at $0. If the test done at home is positive or abnormal, a colonoscopy will be needed. This is considered part of screening and is covered as preventive care.
Other cancer tests
These may include screening for prostate, lung and cervical cancer.
Screening for health conditions
These may include diabetes, depression and osteoporosis.
According to the Affordable Care Act, here’s what is considered non-preventive health care:
Diagnostic Testing and Screening: These are not routine tests and screenings. For example, if your radiologist finds something in your lung cancer screening and wants another, that will be considered a diagnostic test and typically won’t be covered as preventive care.
Additional primary care visits: Most health plans will cover you for an annual checkup with your doctor. Other visits during the same calendar year probably won’t be covered as preventive. For example, let’s say you have flu symptoms and need to visit your doctor virtually or in person—this is not a covered preventive care visit.
Expert Visit: Visiting a specialist (gastroenterologist, orthopedist, neurologist, podiatrist, etc.) for a particular problem does not fall under preventive care.
Alternative Treatment: Treatments such as chiropractic, massage, acupuncture, and other alternative health services are not considered preventive care.
