It was a shocking reveal. One key comment jumped out for those who follow health policy: Retton said she was uninsured, blaming that lack of coverage on 30 orthopedic surgeries that count as “preexisting conditions,” a divorce, and her poor finances.

“I just couldn’t afford it,” Retton told host Hoda Kotb, who did not challenge the assertion.

Retton, who after winning the gold medal in 1984 became a well-known figure — “America’s sweetheart,” appearing on Wheaties boxes and claiming a variety of other endorsements — did not provide details of her income, the illness, the hospital where she was treated, or the type of insurance she was seeking, so it’s hard to nail down specifics.

Nonetheless, her situation can be informative because the reasons she cited for not buying coverage — preexisting conditions and cost — are among the things the Affordable Care Act directly addresses.

Under the law, which has offered coverage through state and federal marketplaces since 2014, insurers are barred from rejecting people with preexisting conditions and cannot charge higher premiums for them, either. This is one of the law’s most popular provisions, according to opinion surveys.

The ACA also includes subsidies that offset all or part of the premium costs for the majority of low- to moderate-income people who seek to buy their own insurance. An estimated “four out of five people can find a plan for $10 or less a month after subsidies on HealthCare.gov,” Health and Human Services Secretary Xavier Becerra said in a written statement when kicking off the annual open enrollment period in November.

Subsidies are set on a sliding scale based on household income with a sizable portion going to those who make less than twice the federal poverty level, which this year is $29,160 for an individual, or $60,000 for a family of four. Premium costs for consumers are capped at 8.5% of household income.

Still, “we know from surveys and other data that, even 10 years on, a lot of people are unaware there are premium subsidies available through ACA marketplaces,” said Sabrina Corlette, co-director of the Center on Health Insurance Reform at Georgetown University.

Those subsidies are one of the reasons cited for record enrollment in 2024 plans, with more than 20 million people signing up so far.

To be sure, there are also many Americans whose share of the premium cost is still a stretch, especially those who might be higher on the sliding subsidy scale. Looking at the KFF subsidy calculator, a 60-year-old with a $100,000 income, for example, would get a $300 monthly subsidy but still have to pay $708 a month toward their premium, on average, nationally. Without a subsidy, the monthly cost would be $1,013.

And even with insurance, many U.S. residents struggle to afford the deductibles, copayments, or out-of-network fees included in some ACA or job-based insurance plans. The ACA does offer subsidies to offset deductible costs for people on the lower end of the income scale. For those with very low incomes, the law expanded eligibility for Medicaid, which is a state-federal program. However, 10 states, including Texas, where Retton lives, have chosen not to expand coverage, meaning some people in this category cannot get either Medicaid or ACA subsidies.

“If her income was below poverty, she could have been caught in the coverage gap,” said Larry Levitt, executive vice president for health policy at KFF. 

Attempts to reach a representative for Retton were not immediately successful.

One last point — ACA enrollment generally must occur during the annual open enrollment, which for 2024 plans opened Nov. 1 and runs until Jan. 16 in most states. But Retton provided no details on what kind of health insurance she shopped for, or when. And there are types of plans and coverage, for example, that fall outside of the ACA rules.

Those include short-term plans, which offer temporary coverage for people between jobs, for example. There are also coverage efforts dubbed “health care sharing ministries,” in which people pool money and pay one another’s medical bills. Neither is considered comprehensive insurance because they generally offer limited benefits, and both can exclude people with preexisting conditions.

If she was considering insurance during a time of year that wasn’t during the open enrollment period, Retton might have still been able to sign up for an ACA plan if she met requirements for a “special enrollment.” Qualifying reasons include a residential move, loss of other coverage, marriage, divorce, and other specific situations.

Retton excelled in landing difficult moves as a gymnast, but she may have missed the bar when it came to buying insurance coverage.

“You can be a very successful person in your other life and not understand American health care and get into a situation that maybe you could have prevented,” said Joseph Antos, a senior fellow at the American Enterprise Institute.

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A nivel nacional, se ha registrado un marcado aumento en las visitas a salas de emergencia y hospitalizaciones por covid-19, influenza y el virus respiratorio sincitial, o VRS, a mediados de diciembre y parece estar ganando impulso.

Aquí hay algunas cosas que debes saber:

¿Qué está circulando ahora?

El virus de covid-19 sigue cambiando, y una versión reciente está ganando terreno en las estadísticas. Aunque apareció solo en septiembre, la variante conocida como JN.1, descendiente de ómicron, se está propagando rápidamente, representando entre el 39% y la mitad de los casos, según estadísticas previas a las vacaciones de los Centros para el Control y Prevención de Enfermedades (CDC).

Los datos de laboratorio indican que las vacunas actualizadas, las pruebas rápidas existentes y los tratamientos médicos para covid-19, son efectivos contra esta última variante.

Otra buena noticia es que “no parece representar riesgos adicionales para la salud pública más allá de los de otras variantes recientes”, según los CDC. Aun así, las nuevas hospitalizaciones por covid-19, que alcanzaron las 34,798 la semana que terminó el 30 de diciembre, están aumentando, aunque las tasas aún son sustancialmente más bajas que las de diciembre pasado.

Sin embargo, es temprano en la temporada. Los niveles del virus en aguas residuales, un indicador de cómo se están propagando las infecciones, son “muy altos”, superando los niveles vistos en esta época el año pasado.

Y no hay que olvidar que hay otros virus desagradables circulando. Más de 20,000 personas fueron hospitalizadas por influenza la semana que terminó el 30 de diciembre, y los CDC informan que el VRS sigue siendo elevado en muchas áreas.

“Hasta ahora, los números definitivamente van en una dirección no muy buena”, dijo Ziyad Al-Aly, jefe del servicio de investigación y desarrollo en el Sistema de Atención Médica de Veteranos de St. Louis y epidemiólogo clínico en la Universidad de Washington en St. Louis. “Es probable que veamos un gran aumento en enero ahora que todos han vuelto a casa después de las vacaciones”.

En comparación con el primer invierno de la pandemia, ahora las cosas están mejor. Muchas menos personas están muriendo o enfermándose gravemente, ya que las vacunas y las infecciones previas brindan cierta inmunidad y reducen la gravedad de la enfermedad.

Incluso en comparación con el invierno pasado, cuando ómicron estaba en aumento, la situación es mejor. Por ejemplo, las nuevas hospitalizaciones son cerca de un tercio de lo que eran alrededor de las vacaciones de 2022. Las muertes semanales disminuyeron ligeramente la última semana de diciembre a 839 y también están muy por debajo de los niveles de hace un año.

“La proporción de enfermedad leve a grave claramente ha cambiado”, dijo William Schaffner, profesor de medicina en la división de enfermedades infecciosas de la Escuela de Medicina de la Universidad de Vanderbilt en Nashville, Tennessee.

Aun así, la definición de “leve” es amplia, haciendo referencia a cualquier cosa que no sea lo suficientemente grave como para requerir hospitalización. Mientras que algunos pacientes pueden tener no más que un resfriado, otros que experimentan covid-19 “leve” pueden sentirse “miserables durante tres a cinco días”, dijo Schaffner.

¿Cómo afectará esto la vida cotidiana? “¿Me voy a enfermar mucho? ¿Tengo que volver a usar mascarilla?”. Es importante saber lo básico.

En primer lugar, es probable que los síntomas de las variantes actuales de covid-19 te resulten familiares, como secreción nasal, dolor de garganta, tos, fatiga, fiebre y dolores musculares. Así que si te sientes mal, quédate en casa, dijo Marcus Plescia, director médico de la Asociación de Funcionarios de Salud Estatales y Territoriales. “Puede marcar una gran diferencia”.

Desempolva esos kits de pruebas caseras de covid-19 en casa, verifica las fechas de caducidad extendidas en el sitio de la FDA y desecha aquellos que hayan expirado. Los tests se pueden comprar en la mayoría de las farmacias y, si aún no has pedido el tuyo, todavía hay kits de prueba gratuitos disponibles a través de un programa federal en covid.gov.

Realiza más de una prueba, especialmente si tus síntomas son leves. Los tests rápidos en casa pueden no detectar la infección por covid-19 en los primeros días, según la FDA, que recomienda usar “múltiples pruebas durante un cierto período de tiempo, como dos o tres días”.

Con los tres virus, aquellos más en riesgo incluyen a los pequeños, los adultos mayores, las embarazadas y aquellos con sistemas inmunes comprometidos o enfermedades subyacentes, como cáncer o problemas cardíacos. Pero incluso aquellos sin factores de alto riesgo también pueden verse afectados negativamente.

Aunque el uso de máscaras ha disminuido en la mayoría de los lugares, es posible que comiences a ver a más personas usándolas en espacios públicos, como tiendas, transporte público o lugares de entretenimiento.

Aunque es poco probable que haya un mandato federal de mascarillas, funcionarios de salud y hospitales en al menos cuatro estados: California, Illinois, Massachusetts y Nueva York, han vuelto a pedir a su personal y pacientes que las usen. Estos requisitos se implementan a través de directivas a nivel de condados.

Los datos de los CDC indican que, a nivel nacional, aproximadamente el 46.7% de los condados están experimentando tasas moderadas a altas de internaciones por covid-19.

“No vamos a ver mandatos generalizados de máscaras, ya que nuestra población no lo encontrará aceptable”, señaló Schaffner. “Dicho esto, a nivel individual, el uso de mascarillas es algo muy inteligente y razonable como una capa adicional de protección”.

Las N95, KN95 y KF94 son las que más protegen. Las de tela y papel no son tan efectivas.

Y, finalmente, si aún no te has vacunado contra covid-19 con una dosis actualizada o recibido una vacuna contra la gripe, no es tarde. También hay nuevas vacunas y anticuerpos monoclonales para proteger contra el VRS recomendados para ciertas poblaciones, que incluyen adultos mayores, embarazadas y niños pequeños.

En general, la gripe alcanza su pico a mediados del invierno y se extiende hasta la primavera. Covid-19, aunque no es técnicamente estacional, tiene tasas más altas en invierno, ya que las personas se agrupan en interiores.

“Si no has recibido las vacunas”, dijo Schaffner, “póntelas sin demora”.

¿No lo vamos a contraer todos? ¿Qué pasa con las reinfecciones?

Las personas que han evitado por completo covid-19 son la minoría.

Al mismo tiempo, las reinfecciones son comunes. El quince por ciento de los encuestados en una reciente encuesta de Yahoo News/YouGov dijo que habían tenido covid dos o tres veces. Una encuesta canadiense publicada en diciembre encontró que 1 de cada 5 residentes dijo que había contraído covid-19 más de una vez hasta junio pasado.

Además del inconveniente de estar enfermo y perder días de trabajo o escuela, continúa el debate sobre si las reinfecciones representan riesgos más pequeños o mayores para efectos de salud graves. No hay respuestas definitivas, aunque expertos siguen estudiando el tema.

Dos investigaciones sugieren que las reinfecciones pueden aumentar las posibilidades de que una persona desarrolle una enfermedad grave o incluso covid-19 prolongado, que se define de diversas maneras pero generalmente significa tener uno o más efectos que persisten durante un mes o más después de la infección.

El porcentaje preciso de casos, y los factores subyacentes, de covid-19 prolongado y por qué las personas lo desarrollan son algunas de las muchas preguntas sin respuesta sobre la afección. Sin embargo, hay un creciente consenso entre los investigadores de que la vacunación protégé.

Aun así, Al-Aly, del VA, dijo que un estudio del que fue coautor y que se publicó en noviembre de 2022 encontró que tener covid-19 más de una vez aumenta “un riesgo adicional de problemas en la fase aguda, ya sea hospitalización o incluso la muerte”, y hace que una persona tenga el doble de probabilidades de experimentar síntomas de covid prolongado.

La encuesta canadiense también encontró un mayor riesgo de covid prolongado entre aquellos que reportaron dos o más infecciones. Ambos estudios tienen sus limitaciones: la mayoría de las 6 millones de personas en la base de datos del VA eran hombres y mayores, y los datos estudiados provenían de los dos primeros años de la pandemia, por lo que algunos reflejaban enfermedades anteriores a la disponibilidad de vacunas. El sondeo canadiense, aunque más reciente, se basó en la auto información de infecciones y condiciones, que pueden no ser precisas.

Aun así, Al-Aly y otros expertos dicen que tomar medidas preventivas, como vacunarse y usar máscara en situaciones de mayor riesgo, puede ser una apuesta segura.

“Incluso si en una infección anterior te salvaste de covid prolongado”, dijo Al-Aly, “no significa que ocurra lo mismo cada vez”.

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Nationally, a sharp uptick in emergency room visits and hospitalizations for covid-19, influenza, and respiratory syncytial virus, or RSV, began in mid-December and appears to be gaining momentum.

Here are a few things to know this time around:

What’s Circulating Now?

The covid virus is continually changing, and a recent version is rapidly climbing the charts. Even though it appeared only in September, the variant known as JN.1, a descendant of omicron, is rapidly spreading, representing between 39% to half of the cases, according to pre-holiday stats from the Centers for Disease Control and Prevention.

Lab data indicates that the updated vaccines, as well as existing covid rapid tests and medical treatments, are effective with this latest iteration. More good news is that it “does not appear to pose additional risks to public health beyond that of other recent variants,” according to the CDC. Even so, new covid hospitalizations — 34,798 for the week that ended Dec. 30 — are trending upward, although rates are still substantially lower than last December’s tally. It’s early in the season, though. Levels of virus in wastewater — one indicator of how infections are spreading — are “very high,” exceeding the levels seen this time last year.

And don’t forget, other nasty bugs are going around. More than 20,000 people were hospitalized for influenza the week ending Dec. 30, and the CDC reports that RSV remains elevated in many areas.

“The numbers so far are definitely going in the not-so-good direction,” said Ziyad Al-Aly, the chief of the research and development service at the Veterans Affairs St. Louis Healthcare System and a clinical epidemiologist at Washington University in St. Louis. “We’re likely to see a big uptick in January now that everyone is back home from the holidays.”

But No Big Deal, Right?

Certainly, compared with the first covid winter, things are better now. Far fewer people are dying or becoming seriously ill, with vaccines and prior infections providing some immunity and reducing severity of illness. Even compared with last winter, when omicron was surging, the situation is better. New hospitalizations, for example, are about one-third of what they were around the 2022 holidays. Weekly deaths dropped slightly the last week of December to 839 and are also substantially below levels from a year ago.

“The ratio of mild disease to serious clearly has changed,” said William Schaffner, a professor of medicine in the division of infectious diseases at Vanderbilt University School of Medicine in Nashville, Tennessee.

Even so, the definition of “mild” is broad, basically referring to anything short of being sick enough to be hospitalized.

While some patients may have no more than the sniffles, others experiencing “mild” covid can be “miserable for three to five days,” Schaffner said.

How Will This Affect My Day-to-Day Life?

“Am I going to be really sick? Do I have to mask up again?” It is important to know the basics.

For starters, symptoms of the covid variants currently circulating will likely be familiar — such as a runny nose, sore throat, cough, fatigue, fever, and muscle aches.

So if you feel ill, stay home, said Marcus Plescia, chief medical officer of the Association of State and Territorial Health Officials. “It can make a big difference.”

Dust off those at-home covid test kits, check the extended expiration dates on the FDA website, and throw away the ones that have aged out. Tests can be bought at most pharmacies and, if you haven’t ordered yours yet, free test kits are still available through a federal program at covid.gov.

Test more than once, especially if your symptoms are mild. The at-home rapid tests may not detect covid infection in the first couple of days, according to the FDA, which recommends using “multiple tests over a certain time period, such as two to three days.”

With all three viruses, those most at risk include the very young, older adults, pregnant people, and those with compromised immune systems or underlying diseases, including cancer or heart problems. But those without high-risk factors can also be adversely affected.

While mask-wearing has dropped in most places, you may start to see more people wearing them in public spaces, including stores, public transit, or entertainment venues.

Although a federal mask mandate is unlikely, health officials and hospitals in at least four states — California, Illinois, Massachusetts, and New York — have again told staff and patients to don masks. Such requirements were loosened last year when the public health emergency officially ended.

Such policies are advanced through county-level directives. The CDC data indicates that, nationally, about 46.7% of counties are seeing moderate to high hospital admission rates of covid.

“We are not going to see widespread mask mandates as our population will not find that acceptable,” Schaffner noted. “That said, on an individual basis, mask-wearing is a very intelligent and reasonable thing to do as an additional layer of protection.”

The N95, KN95, and KF94 masks are the most protective. Cloth and paper are not as effective.

And, finally, if you haven’t yet been vaccinated with an updated covid vaccine or gotten a flu shot, it’s not too late. There are also new vaccines and monoclonal antibodies to protect against RSV recommended for certain populations, which include older adults, pregnant people, and young children.

Generally, flu peaks in midwinter and runs into spring. Covid, while not technically seasonal, has higher rates in winter as people crowd together indoors.

“If you haven’t received vaccines,” Schaffner said, “we urge you to get them and don’t linger.”

Aren’t We All Going to Get It? What About Repeat Infections?

People who have dodged covid entirely are in the minority.

At the same time, repeat infections are common. Fifteen percent of respondents to a recent Yahoo News/YouGov poll said they’d had covid two or three times. A Canadian survey released in December found 1 in 5 residents said they had gotten covid more than once as of last June.

Aside from the drag of being sick and missing work or school for days, debate continues over whether repeat infections pose smaller or larger risks of serious health effects. There are no definitive answers, although experts continue to study the issue.

Two research efforts suggest repeat infections may increase a person’s chances of developing serious illness or even long covid — which is defined various ways but generally means having one or more effects lingering for a month or more following infection. The precise percentage of cases — and underlying factors — of long covid and why people get it are among the many unanswered questions about the condition. However, there is a growing consensus among researchers that vaccination is protective.

Still, the VA’s Al-Aly said a study he co-authored that was published in November 2022 found that getting covid more than once raises an “additional risk of problems in the acute phase, be it hospitalization or even dying,” and makes a person two times as likely to experience long covid symptoms.

The Canadian survey also found a higher risk of long covid among those who self-reported two or more infections. Both studies have their limitations: Most of the 6 million in the VA database were male and older, and the data studied came from the first two years of the pandemic, so some of it reflected illnesses from before vaccines became available. The Canadian survey, although more recent, relied on self-reporting of infections and conditions, which may not be accurate.

Still, Al-Aly and other experts say taking preventive steps, such as getting vaccinated and wearing a mask in higher-risk situations, can hedge your bets.

“Even if in a prior infection you dodged the bullet of long covid,” Al-Aly said, “it doesn’t’ mean you will dodge the bullet every single time.”

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The annual regulatory proposal, known as the payment parameters rule, also seeks to expand access to adult dental coverage in Affordable Care Act marketplaces and would require states to hold open enrollment periods for Obamacare plans at the same time of year. It’s likely one of the last major ACA policy efforts of President Joe Biden’s first term — and, if he loses reelection, could represent his final touches on the landmark health program created when he was vice president.

Biden has been a staunch supporter of Obamacare and has taken steps during his own first term in the White House to expand the program through rules and legislation, including measures that increased premium subsidies. In part because of those subsidies, enrollment has increased steadily and hit records under his watch.

The proposal for 2025 would continue administration efforts to expand coverage, making it easier for states to offer plans that include adult dental care. The rules also set additional guardrails on the growing number of states that have chosen to run their own ACA marketplaces.

The rules need to be finalized in the spring and would affect plans starting in January 2025, not long before Inauguration Day.

So expect some controversy.

Already, the ACA has entered the political debate, with the current GOP front-runner, former President Donald Trump, taking to his Truth Social site on Thanksgiving weekend to call the failure of the GOP to repeal the ACA “a low point for the Republican Party.”

Trump also said he was “seriously” considering alternatives, which harked back to his presidency when he frequently promised an Obamacare replacement was soon to be revealed. It never was.

Biden quickly seized on Trump’s comments, saying on Nov. 27 that “my predecessor has once again — God love him — called for cuts that could rip away health insurance for tens of millions of Americans.”

Many of the changes made during Biden’s term, especially to rules that spell out how the law is to be implemented, could be altered if a Republican wins the White House — just as occurred in the transition from the Obama administration to the Trump term and, again, when Biden took office.

When Trump came into office, for example, he made a number of moves to roll back ACA rules set by the program’s namesake, President Barack Obama, including sharply reducing funding for enrollment assistance, shortening the annual sign-up period, and allowing less expensive but less protective short-term plans to cover longer periods of time. Biden’s team, in turn, expanded funding for enrollment, added special enrollment periods, and has a proposal awaiting final approval that would restore restrictions on short-term plans, which don’t cover many of the benefits included in ACA plans and are often called “junk insurance” by critics.

“If the past is any guide, and the next administration is different, the first thing they will do is roll things back,” said Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

Politics may be one reason the administration’s latest proposal doesn’t include larger changes to the ACA. Doing anything more aggressive in an election year “might disrupt a program that Biden fully supports,” said Joseph Antos, senior fellow at the American Enterprise Institute, a right-leaning think tank.

But the proposal from the Department of Health and Human Services does respond to concerns about “network adequacy,” or whether insurers’ doctor and hospital networks are large enough to meet demand. The rules would require states to set numerical standards, such as a maximum “time and distance” that patients must travel to access in-network care, that are at least as rigorous as federal limits that kicked in this year.

The proposal would affect the 18 states, plus the District of Columbia, that run their own ACA marketplaces.

While many of them already set some network parameters, the standards vary. The administration’s latest proposal notes that 25% of existing state rules fail to set any quantitative requirements, such as how long or far a patient might have to drive to find a participating provider, or the acceptable ratio of the number of enrollees in a plan to the number of covered medical providers.

Requiring standards at least as tough as federal exchange rules across all states “would enhance consumer access to quality, affordable care,” the document says.

Some states “may not be doing enough to ensure compliance,” said Corlette. “States will have to step up their game.”

States would also have to review insurer networks to see if they meet the standards before giving the go-ahead to sell their plans. While the federal marketplace will, beginning in 2025, require insurers to meet new rules aimed at limiting patients’ wait times for appointments, especially for primary care and behavioral health, state marketplaces won’t yet have to impose similar standards.

More prescriptive state requirements for ACA insurers might draw some pushback during the public comment period for the rules, which runs through Jan. 8. They could also be a target for change if the GOP wins the White House, said Chris Condeluci, a health law attorney who worked as counsel to the Senate Finance Committee when the ACA was drafted.

“On the one hand, it makes sense to have standardized rules so everyone is working off the same song sheet,” said Condeluci. But he said there’s support for the idea that state marketplaces were not “to be nationally run or overly prescriptive from a federal government regulatory perspective.”

The HHS proposal also seeks to expand access to routine adult dental coverage by eliminating a prohibition against states including the care as an “essential health benefit” in their benchmark plans. The rules would also standardize open enrollment periods across all states, requiring them to begin Nov. 1 and run through at least Jan. 15. Most states already do that, although Idaho’s period currently begins Oct. 15 and ends Dec. 15, and New York’s begins Nov. 16 and ends Jan. 31.

The payment parameter notices, though dryly named, are a big deal not only for insurers, who plan their benefits and set their rates based in part on such rules, but also for consumers.

The ACA marketplaces “cover millions of people and it’s very important to make sure they are working and people understand what they are buying,” said Bethany Lilly, executive director of public policy at the Leukemia & Lymphoma Society.

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Changes on tap for 2025? For one, the administration wants states that run their own ACA marketplaces to crack down on what’s called “network adequacy” — how many doctors, hospitals and other providers Obamacare insurers include in their covered networks.

The Health 202 is a coproduction of The Washington Post and KFF Health News.

The regulatory proposal, known in Washington as the payment parameters notice, came out on Nov. 15. Arriving in the run-up to a presidential election, the proposed rules could be finalized in the spring and would take effect in January 2025, not long before Inauguration Day.

Should President Biden fail to fend off his likely Republican challenger, former president Donald Trump, Obamacare and the insurance markets it created could start to look a lot different. Biden, of course, has been a staunch supporter of the ACA and has taken steps to expand the program through both rulemaking and legislation, including measures that increased premium subsidies. Enrollment has hit records under his watch.

But over Thanksgiving weekend, Trump posted on his Truth Social site that the GOP’s failure to repeal the ACA in his first term was “a low point for the Republican Party.”

He’s “seriously” considering alternatives, Trump added — harking back to his presidency, when he repeatedly promised he was about to reveal an Obamacare replacement plan. Spoiler alert — he never did.

• “Obamacare Sucks!!!” he added in a middle-of-the-night post on Nov. 29.

That’s a softball for Democrats. Obamacare has grown to be largely popular with Americans, according to KFF, which has long tracked public opinion of the law. Trump’s failed attempt to repeal it helped cost his party control of the House in 2018, exit polls indicated.

Biden seized on Trump’s posts, saying Monday at the White House that “my predecessor once again called for cuts that could rip away health insurance for tens of millions of Americans.” 

Behind the back and forth between the men, however, is a reality: Many of the changes made during Biden’s term, especially those in regulations, could be altered if there’s a new administration elected next year — just as Biden did when he took office, and Trump before him.

Trump, for example, rolled back ACA actions by his predecessor, President Barack Obama, including sharply reducing funding for enrollment assistance, shortening the annual sign-up period and loosening rules so less expensive short-term plans could be sold for longer periods.

Biden’s team, in turn, expanded funding for enrollment, added special enrollment periods, and has a proposal awaiting final approval that would restore restrictions on short-term plans, which don’t cover many benefits required by the ACA and are called “junk insurance” by critics.

But the latest payment parameters notice from Health and Human Services is a modest set of tweaks that, in part, aims to address concern about whether ACA insurers cover enough doctors and hospitals to meet demand. The network adequacy provision would require states to set numerical standards, such as  the maximum time or distance patients might have to travel to access in-network care, that are at least as tough as the rules the feds impose on insurers in its exchange. A quarter of states running their own marketplaces don’t have any such quantitative standards, according to CMS.

In addition, the payment rule would:

• Seek to expand access to routine adult dental coverage by allowing states to add the care to essential benefits in their benchmark plans. That’s currently not allowed.
• Standardize open enrollment periods across all states to start Nov. 1 and run at least through Jan. 15. Most states already do that, although Idaho currently opens Oct. 15 and ends Dec. 15.

“If the past is any guide, and the next administration is different, the first thing they will do is roll things back,” said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University.

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As of this year, commercial insurers have enticed just over half of all Medicare beneficiaries — or nearly 31 million people — to sign up for their plans instead of traditional Medicare. The plans typically include drug coverage as well as extras like vision and dental benefits, many at low or even zero additional monthly premiums compared with traditional Medicare.

But even as enrollment soars, so too has friction between insurers and the doctors and hospitals they pay to care for beneficiaries. Increasingly, according to experts who watch insurance markets, hospital and medical groups are bristling at payment rates Medicare Advantage plans impose and at what they say are onerous requirements for preapproval to deliver care and too many after-the-fact denials of claims.

The insurers say they’re just trying to control costs and avoid inappropriate care. The disputes are drawing more attention now, during the annual open enrollment period for Medicare, which runs until Dec. 7.

Stuck in the middle are patients. People whose preferred doctors or hospitals refuse their coverage may have to switch Medicare Advantage plans or revert to the traditional program, although it can be difficult or even impossible when switching back to obtain what is called a “Medigap” policy, which covers some of the traditional plan’s cost-sharing requirements.

For example, more than 30,000 San Diego-area residents are looking for new doctors after two large medical groups affiliated with Scripps Health said they would no longer contract with Medicare Advantage insurers.

“The insurance companies running the Medicare Advantage plans are pushing physicians and hospitals to the edge,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents the for-profit hospital sector.

The insurance industry’s lobbying arm, AHIP, said in a February letter to the Centers for Medicare & Medicaid Services that prior approvals and other similar reviews protect patients by reducing “inappropriate care by catching unsafe or low-value care, or care not consistent with the latest clinical evidence.”

AHIP spokesperson David Allen said in an email that Medicare Advantage plans are growing in enrollment because people like them, citing surveys conducted by an AHIP-backed coalition.

The vast majority, he wrote, said they were satisfied with their plans and the access to care they provide.

The disputes so far don’t appear to center on any particular insurer, region, or medical provider, although both UnitedHealthcare and Humana Inc. — the two largest Medicare Advantage insurers — are among those that have had contracts canceled.

Baptist Health in Louisville, Kentucky, said in a statement that all nine of its hospitals, along with its clinics and physician groups, would cut ties with Advantage plans offered by UnitedHealthcare and Wellcare Health Plans Inc. beginning in January unless they reach an agreement.

“Many Medicare Advantage plans routinely deny or delay approval or payment for medical care recommended by a patient’s physician,” Baptist Health said in its statement.

The system’s medical group, with nearly 1,500 physicians and other providers, left Humana’s network in September.

In a similar move, Brunswick, Georgia-based Southeast Georgia Health System, which includes two hospitals, two nursing homes, and a physician network, warned this fall that it would end its contract with Centene Corp.’s Wellcare Medicare Advantage plans in December, citing what it said was years of “inappropriate payment of claims and unreasonable denials.”

In some cases, health systems’ threats to abandon Advantage plans — as well as insurers’ threats not to include providers in their networks — are negotiating tactics, intended as leverage to win concessions on payment rates or other issues. And some have been resolved. Ohio’s Adena Regional Medical Center, for example, said in September it would drop Medicare Advantage plans offered by Elevance Health, formerly known as Anthem Inc., but reinstated them following additional negotiations.

Still, some hospital and policy experts say the conflicts may be the beginning of a trend.

“This seems different,” said David Lipschutz, associate director and senior policy attorney at the Center for Medicare Advocacy, who said hospitals and doctors are becoming “much more vocal” about their frustration with some cost-control efforts by Medicare Advantage insurers.

“There have been serious problems with payment suspensions and reviews that annoy the providers. I would not be surprised if we start to see more of this pushback” as the Medicare market becomes more concentrated among a handful of insurers, said Don Berwick, president emeritus and senior fellow at the Institute for Healthcare Improvement and a former CMS administrator.

While availability varies from county to county, Medicare beneficiaries can choose on average among 43 plans, according to KFF. UnitedHealthcare and Humana account for about half of the nationwide enrollment in Advantage plans.

Studies show that Medicare Advantage costs taxpayers more per beneficiary than the traditional program. But the plans enjoy the backing of many lawmakers, especially Republicans, because of their popularity.

The Health and Human Services Department’s inspector general reported last year that some Advantage plans have denied coverage for care that should have been provided under Medicare’s rules.

The report examined prior authorization requests — a requirement to seek insurers’ OK before certain treatments, procedures, or hospital stays — and claims denials, where insurers refuse to pay for all or part of care that’s already been performed.

Lawmakers have recently demanded additional information from Advantage insurers about the factors they use to make such determinations.

CMS proposed a rule this month to cap commissions for brokers who sell Medicare Advantage plans and require more detail on how the plans’ prior approval programs affect certain low-income enrollees and people with disabilities.

Lipschutz said the HHS inspector general’s study may have encouraged hospitals and doctors to be more outspoken.

The inspector general’s office found that 13% of the denied requests for treatment it reviewed and 18% of denied claims were for care that should have been covered. Responding in part to that report, the Biden administration issued a rule set to take effect in January that requires Medicare Advantage plans to provide “the same medically necessary care” as the traditional program. Every Advantage insurer must also annually review its own policies to make sure they match those in the traditional program.

The American Hospital Association, while lauding the administration’s action, questioned whether it would be enough. In a letter sent last month to CMS, the hospital lobbying group said its members “have heard from some [insurers] that they either do not plan to make any changes to their protocols” or “have made changes to their denial letter terminology or procedures in a way that appears to circumvent the intent of the new rules.” The letter urged “rigorous oversight” by CMS.

Allen, the AHIP spokesperson, did not respond to a request to comment on the AHA letter.

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But among doctors and hospitals, it’s a different story.

The Health 202 is a coproduction of The Washington Post and KFF Health News.

Across the country, provider grumbling about claim denials and onerous preapproval requirements by Advantage plans is crescendoing. Some hospitals and physician practices are so fed up they’re refusing to accept the plans — even big ones like those offered by UnitedHealthcare and Humana.

“The insurance companies running the Medicare Advantage plans are pushing physicians and hospitals to the edge,” said Chip Kahn, president and CEO of the Federation of American Hospitals, which represents the for-profit hospital sector.

Last week, the industry’s largest lobbying group, the American Hospital Association, fired off a letter to the Centers for Medicare and Medicaid Services warning that some insurers seem intent on circumventing new rules put in place by the Biden administration aimed at reining in some prior authorization and claim denials.

It isn’t like we’ve never seen disputes between insurers and providers before, especially in negotiations with employer-sponsored plans.

But the focus now on Medicare Advantage “seems different,” said David Lipschutz, associate director and senior policy attorney for the Center for Medicare Advocacy, who says hospitals and doctors are becoming “much more vocal” about their frustrations with some of the insurers’ cost-control efforts.

Baptist Health in Louisville, for example, has threatened that all of its nine hospitals, along with its clinics and physician groups, will cut ties with Advantage plans offered by UnitedHealthcare and WellCare Health Plans Inc. beginning in January unless they can come to terms.

The plans “routinely deny or delay approval or payment for medical care recommended by your physician,” the system wrote in a message to patients posted on its website.

The system’s medical group, with nearly 1,500 physicians and other providers, left Humana’s network in September.

And in San Diego, more than 30,000 people are looking for new doctors after two large medical groups affiliated with Scripps Health said they would no longer contract with any Medicare Advantage insurers. Revenue “is not sufficient to cover the cost of patient care we provide,” they said in a statement.

Lipschutz thinks providers are feeling emboldened following a study by the Health and Human Services Department’s inspector general published last year that found some Advantage plans have denied coverage for care that should have been provided under Medicare’s rules.

The Biden administration’s new rules, set to take effect in January, are in part a response to the OIG report. Enrollment for Medicare Advantage plans, traditional Medicare coverage and stand-alone Medicare drug plans is open until Dec. 7.

While the insurance industry likes to boast that a huge majority of Congress supports the plans, there’s increasing scrutiny at the Capitol, too.

Prior approval is a big point of friction. Virtually all Medicare Advantage enrollees are in plans that require the insurer to sign off in advance for at least some care, according to KFF. Insurers say that process ensures treatments are coordinated and appropriate.

In 2021, more than 35 million requests for prior approval were submitted for Medicare Advantage enrollees, according to KFF, and over 2 million of them were denied. For the small minority of patients who appeal (11 percent), a whopping 82 percent won a full or partial overturning of the insurers’ decision.

To be sure, commercial plans covering people with job-based insurance or those who buy their own through the Affordable Care Act also engage in prior approval, and there’s lots of complaints about them, too.

The difference with Medicare, though, is that beneficiaries can choose the traditional, government-run program, in which prior approval and claim denials are much more limited. Doctors and hospitals have plenty of gripes about how much traditional Medicare pays them, but from their point of view, they spend less time fighting over medical decisions.

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La inscripción abierta comienza el 1 de noviembre para el mercado federal, cuidadodesalud.gov, y los mercados estatales. Los consumidores pueden ir en línea, llamar o buscar ayuda de un corredor, o un navegador, para conocer sus opciones de cobertura para 2024, calcular sus posibles subsidios o cambiar de plan.

En la mayoría de los estados, la inscripción abierta dura hasta el 15 de enero, aunque algunos tienen períodos diferentes. El de California, por ejemplo, es más largo, hasta el 31 de enero, pero el de Idaho va desde el 15 de octubre hasta el 15 de diciembre.

En general, la inscripción debe realizarse antes del 15 de diciembre para obtener cobertura que comience el 1 de enero. Si el plan se adquiere en enero, entrará en vigencia el 1 de febrero.

Expertos en política de salud y corredores recomiendan que todos los titulares de pólizas de ACA al menos revisen las opciones del próximo año, porque los precios, y los médicos y hospitales en las redes de los planes, pueden haber cambiado.

Podría ser otro año récord. Ahora estos planes están bien establecidos: se estima que más de 16.3 millones de personas se inscribieron el año pasado. Y este año podrían ser aún más. Se mejoró la ayuda disponible, cambios que se aprobaron en el apogeo de la pandemia de COVID-19 que siguen vigentes, y algunos estados han aumentado la ayuda financiera de otras maneras.

Además, millones de personas en todo el país están perdiendo la cobertura de Medicaid a medida que los estados reevalúan la elegibilidad de los afiliados por primera vez desde el inicio de la pandemia.

Muchas de las personas excluidas podrían ser elegibles para un plan de ACA. Pueden inscribirse tan pronto como sepan que están perdiendo la cobertura de Medicaid, incluso fuera de la temporada de inscripción abierta.

Una advertencia importante: no esperes hasta el último minuto, especialmente si estás buscando ayuda de un corredor. Este año, se les pedirá a los consumidores que certifiquen que acordaron voluntariamente la ayuda de los corredores y que la información sobre sus ingresos y otros datos proporcionada por los corredores es precisa.

“Es una buena protección para ambas partes”, dijo el corredor Joshua Brooker, fundador de PA Health Advocates en Pennsylvania. Pero los corredores están preocupados de que este requisito pueda causar demoras, especialmente si los clientes esperan hasta último momento para buscar un plan médico.

Las primas están cambiando. Mientras que algunos planes de salud están reduciendo las primas (el pago mensual por la cobertura) para el próximo año, muchos las están aumentando, generalmente entre un 2% y un 10%, según una revisión inicial de las solicitudes de tarifas de Peterson-KFF Health System Tracker. El aumento medio es del 6%.

Las primas, ya sea que suban o bajen, varían ampliamente por región y por aseguradora.

Expertos dicen que esa es una gran razón para iniciar una sesión en el sitio web federal, cuidadodesalud.gov, en los 32 estados que lo utilizan, o en el mercado de seguros para uno de los 18 estados y el Distrito de Columbia que administran sus propias plataformas. Cambiar de aseguradora podría significar una prima más baja.

“Todo es muy localizado”, dijo Sabrina Corlette, profesora de investigación y co-directora del Centro de Reformas de Seguros de Salud en la Universidad de Georgetown. “La gente debería comprar para maximizar su subsidio, aunque eso podría requerir no solo cambiar a un nuevo plan, sino también a una nueva red de proveedores”.

La mayoría de las personas que compran su propia cobertura califican para créditos fiscales, que es un subsidio para compensar parte o incluso la totalidad de la prima mensual.

Los subsidios se basan en parte en la prima del segundo plan de nivel de Plata de precio más bajo en una región. Cuando estas primas suben o bajan, posiblemente porque una nueva aseguradora entra en el mercado con tarifas iniciales bajas, afecta la cantidad del subsidio.

Los ingresos del hogar también son un factor. Los subsidios se calculan en una escala móvil basada en los ingresos.

Los subsidios aumentaron durante la pandemia, para que más inscriptos pudieran recibirlos y para permitir que más familias calificaran. Esas mejoras se extendieron hasta 2025 por la Ley de Reducción de la Inflación del presidente Joe Biden, aprobada el año pasado.

Las calculadoras en línea, incluida una en cuidadodesalud.gov, pueden proporcionar estimaciones de subsidios.

Es posible que califiques para deducibles y copagos más bajos. Además de los subsidios para las primas, la mayoría de los inscritos en estos planes califican para deducibles reducidos, copagos y otros tipos de costos compartidos si sus ingresos no superan 2.5 veces el nivel federal de pobreza, o alrededor de $75,000 para una familia de cuatro personas.

Los planes de ACA se agrupan en niveles de colores: Bronce, Plata, Oro y Platino, en gran parte según cuánto requieran de costos compartidos. Los planes de Bronce ofrecen las primas más bajas, pero generalmente los copagos y deducibles más altos. Los planes de Platino tienen las primas más altas, pero gastos de bolsillo más bajos para la atención médica

Las reducciones en los costos compartidos solo están disponibles en planes de nivel de Plata y son más generosas para aquellos en el extremo inferior de la escala de ingresos. Una novedad de este año: para ayudar a más personas a calificar, el mercado federal cambiará automáticamente a las personas elegibles a un plan de Plata para el próximo año si actualmente están inscritas en un plan de Bronce, siempre y cuando el inscrito no haya hecho un ajuste en la cobertura por sí mismo.

Hay salvaguardias incorporadas, dijo Louise Norris, experta en seguros y corredora, para que las personas sean inscritas automáticamente en un plan con la misma red de proveedores médicos y una prima similar o más baja. Además, nueve de los estados que administran sus propios mercados, California, Colorado, Connecticut, Maryland, Massachusetts, Nueva Jersey, Nuevo México, Vermont y Washington, han mejorado sus programas de reducción de costos compartidos al extender la elegibilidad o aumentar los beneficios.

Algunos jóvenes de 26 años podrán permanecer en los planes de sus padres por más tiempo. Algunos que tienen cobertura a través de sus padres podrán permanecer en ella hasta el final del año calendario en el que cumplen 26 años, en lugar de perder la cobertura el mismo día de su cumpleaños 26. Esto se ha convertido en regulación.

Los estados que administran sus propios mercados pueden establecer reglas similares, y algunos ya permiten períodos más largos en el plan de los padres.

Las redes pueden seguir siendo pequeñas. A menudo, los planes de salud intentan reducir las primas asociándose con un conjunto limitado de médicos, hospitales y otros proveedores. Esos pueden cambiar de un año a otro, por lo que expertos en seguros como Norris dicen que los inscritos siempre deben verificar sus planes durante la inscripción abierta para asegurarse de que sus médicos y hospitales preferidos estén incluidos en la red. También es una buena idea observar detenidamente los cambios en la cobertura de medicamentos recetados o en los copagos, agregó.

“El mensaje general es no asumir nada y asegurarse de verificar quién está en la red”, enfatizó Norris.

El año pasado, la administración Biden estableció reglas que requerían que los planes de salud tuvieran suficientes proveedores en la red para cumplir con estándares específicos de tiempo de viaje y distancia. Una propuesta para limitar cuánto tiempo esperan los pacientes para una cita de rutina se ha retrasado hasta 2025.

Lo que todavía no sabemos. Hay algunas cosas inciertas a medida que se acerca el final del año. Por ejemplo, la administración Biden propuso este verano revertir una regla de la era Trump que permitía la venta de planes de corto plazo para períodos de cobertura de hasta un año.

Los planes de corto plazo no cumplen con los requisitos de ACA, y muchos tienen menos beneficios y pueden establecer restricciones en la cobertura, incluido no permitir que los adquieran personas con afecciones preexistentes como diabetes o colesterol alto. Como resultado, son mucho menos costosos que los planes del mercado. La propuesta de Biden los limitaría a períodos de cobertura de cuatro meses, pero la regla aún no es definitiva.

También está pendiente una regla final que permitiría a las personas inscribirse en la cobertura de ACA si fueron traídas a Estados Unidos por sus padres cuando eran pequeños, sin estatus legal permanente, el grupo conocido como “Dreamers”.

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Open enrollment starts Nov. 1 for the ACA’s federal and state exchanges. Consumers can go online, call, or seek help from a broker or other assister to learn their 2024 coverage options, calculate their potential subsidies, or change plans.

In most states, open enrollment lasts through Jan. 15, although some states have different time periods. California’s, for example, is longer, open until Jan. 31, but Idaho’s runs from Oct. 15 to Dec. 15. In most states enrollment must occur by Dec. 15 to get coverage that begins Jan. 1.

Health policy experts and brokers recommend all ACA policyholders at least look at next year’s options, because prices — and the doctors and hospitals in plans’ networks — may have changed.

It Could Be Another Record Year

ACA plans are now well entrenched — an estimated 16.3 million people signed up during open enrollment last year. This year may see even larger numbers. Enhanced subsidies first approved during the height of the covid pandemic remain available, and some states have boosted financial help in other ways.

In addition, millions of people nationwide are losing Medicaid coverage as states reassess their eligibility for the first time since early in the pandemic. Many of those ousted could be eligible for an ACA plan. They can sign up as soon as they know they’re losing Medicaid coverage — even outside of the open enrollment season.

Another important caution: Don’t wait until the last minute, especially if you are seeking help from a broker. Consumers this year will be asked to certify that they voluntarily agreed to brokers’ assistance and that their income and other information provided by brokers is accurate.

It’s a good protection for both parties, said broker Joshua Brooker, founder of PA Health Advocates in Pennsylvania. But brokers are concerned the requirement could cause delays, especially if clients wait until right before the end of open enrollment to apply.

“Brokers will need to stop what they are doing right at the end before they click ‘submit’ and wait for the consumer to sign a statement saying they reviewed the policy,” Brooker said.

Premiums Are Changing

While some health plans are lowering premiums for next year, many are increasing them, often by 2% to 10%, according to a Peterson-KFF Health System Tracker initial review of rate requests. The median increase, based on a weighted average across its plans for each insurer, was 6%. 

Premiums, and whether they go up or down, vary widely by region and insurer. 

Experts say that’s a big reason to log on to the federal website, healthcare.gov, in the 32 states that use it, or on to the insurance marketplace for one of the 18 states and the District of Columbia that run their own. Changing insurers might mean a lower premium.

“It’s very localized,” said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University. “People should shop to maximize their premium tax credit, although that might require not only changing to a new insurance plan, but potentially also a new network of providers.”

Most people buying their own coverage qualify for the tax credit, which is a subsidy to offset some, or even all, of their monthly premium. Subsidies are based partly on the premium of the second-lowest-priced silver-level plan in a region. When those go up or down, possibly from a new insurer entering the market with low initial rates, it affects the subsidy amount.

Household income is also a factor. Subsidies are on a sliding scale based on income.

Subsidies were enhanced during the pandemic, both to increase the amount enrollees could receive and to allow more families to qualify. Those enhancements were extended through 2025 by President Joe Biden’s Inflation Reduction Act, passed last year.

Online calculators, including one at healthcare.gov, can provide subsidy estimates.

You May Qualify for Lower Deductibles and Copays

In addition to the premium subsidies, most ACA enrollees qualify for reduced deductibles, copayments, and other types of cost sharing if their income is no more than 2.5 times the federal poverty level, or about $75,000 for a family of four or $36,450 for a single-person household.

ACA plans are grouped into colored tiers — bronze, silver, gold, and platinum — based largely on how much cost sharing they require. Bronze plans offer the lowest premiums but usually the highest copayments and deductibles. Platinum plans carry the highest premiums but the lowest out-of-pocket expenses for care.

Cost-sharing reductions are available only in silver-level plans and are more generous for those on the lower end of the income scale. New this year: To help more people qualify, the federal marketplace will automatically switch eligible people to a silver plan for next year if they are currently enrolled in a bronze plan, as long as the enrollee has not made an adjustment in coverage themselves.

There are safeguards built in, said insurance expert and broker Louise Norris, so that people are auto-enrolled in a plan with the same network of medical providers and a similar or lower premium. Additionally, nine of the states that run their own marketplaces — California, Colorado, Connecticut, Maryland, Massachusetts, New Jersey, New Mexico, Vermont, and Washington — have enhanced their cost-sharing reduction programs by extending eligibility or increasing benefits.

Some 26-Year-Olds Will Get to Stay on Parents’ Plans Longer

Happy birthday! Existing federal marketplace rules allowing adult children to stay on their parents’ plans though the calendar year in which they turn 26, rather than lose coverage on their 26th birthday, were codified into regulation.

States that run their own markets can set similar rules, and some already allow for longer periods on a parent’s plan.

Networks May Still Be Small

Insurance plans often try to reduce premiums by partnering with a limited set of doctors, hospitals, and other providers. Those can change year to year, which is why insurance experts like Norris say enrollees should always check their plans during open enrollment to ensure their preferred physicians and medical centers are included in the network.

It’s also a good idea, Norris said, to look closely for changes in prescription drug coverage or copayments.

“The general message is, don’t assume anything and make sure you check to see who is in the network,” Norris said.

Last year, the Biden administration set rules requiring health plans to have enough in-network providers to meet specific driving time and distance standards. A proposal to limit how long patients wait for a routine appointment has been delayed until 2025.

What We Still Don’t Know

A few things remain uncertain as the end of the year approaches. For example, the Biden administration proposed this summer to reverse a Trump-era rule that allowed short-term insurance plans to be sold for coverage periods of up to a year.

Short-term plans are not ACA-compliant, and many have fewer benefits and can set restrictions on coverage, including barring people with health conditions from purchasing them. As a result, they are far less expensive than ACA plans. The Biden proposal would restrict them to coverage periods of four months, but the rule isn’t final.

Also pending: a final rule that would allow people to sign up for ACA coverage if they were brought to the U.S. as children by parents lacking permanent legal status — a group known as “Dreamers.”

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Her answers on the form led her primary care doctor to ask about depression and her mood, and Rogers said she answered honestly.

“It was a horrible year. I lost my mom,” Rogers said she told her physician.

After what Rogers estimates was a five-minute conversation about depression, the visit wrapped up. She said her doctor did not recommend treatment nor refer her for counseling.

“It’s not like anything I told her triggered, ‘Oh my goodness, I’m going to prescribe you medication,’” she said.

Then the bill came.

The Patient: Christine Rogers, 60, a public relations/communications worker who is insured by Cigna Healthcare through her job.

Medical Services: An annual wellness visit, which included typical blood tests, as well as a depression screening and discussion with a physician.

Service Provider: WakeMed Physician Practices, part of WakeMed Health & Hospitals, a Raleigh-based, tax-exempt system with three acute care hospitals, outpatient centers, and hundreds of physicians across a range of specialties.

Total Bill: $487, which included a $331 wellness visit and a separate $156 charge for what was billed as a 20- to 29-minute consultation with her physician. Her insurer paid $419.93, leaving Rogers with a $67.07 charge related to the consultation.

What Gives: Rogers said the bill came as a surprise because she knows annual wellness checks are typically covered without patient cost sharing as preventive care under the Affordable Care Act. And as part of an annual physical, patients routinely fill out a health questionnaire, which may cover mental health topics.

But there is a catch: Not all care that may be provided during a wellness visit counts as no-cost preventive care under federal guidelines. If a health issue arises during a checkup that prompts discussion or treatment — say, an unusual mole or heart palpitations — that consult can be billed separately, and the patient may owe a copayment or deductible charge for that part of the visit.

In Rogers’ case, a brief chat with her doctor about mental health triggered an additional visit charge — and a bill she was expected to pay.

Rogers said she didn’t broach the subject of depression during her checkup. She was asked when she checked in to fill out the questionnaire, she said — and then the doctor brought it up during her exam.

The Affordable Care Act requires insurers to cover a variety of preventive services without a patient paying out-of-pocket, with the idea that such care might prevent problems or find them early, when they are more treatable and less costly.

The federal government lists dozens of services that are classified as no-cost-sharing preventive care for adults and children, such as cancer screenings, certain vaccinations, and other services recommended by either of two federal agencies or the U.S. Preventive Services Task Force, an independent group of experts in disease prevention.

Depression screening is covered as preventive care for adults, including when they’re pregnant or in the postpartum phase.

Rogers requested an itemized bill from her doctor’s practice, which is part of WakeMed Physician Practices. It showed a charge for the wellness visit (free for her), as well as a separate charge for a 20- to 29-minute office visit. Earlier, Rogers said, she had discussed the initial bill with the office manager at her doctor’s office, who told her the separate charge, roughly $67, was for discussing her questionnaire results with her doctor.

For Rogers, it wasn’t so much about the $67 she owed for the visit, as it was a matter of principle. The separate change, she said, was “disingenuous” because she was specifically asked about her mental health.

Also, annual physicals are intended to nip health problems in the bud, which sometimes requires a few more minutes of attention — whether to discuss symptoms of depression or palpate an abdomen for digestive issues.

Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University, agrees the charge seemed a bit over-the-top: Depression screening “is now a recommended part of the annual physical,” she said. “Implicit in that is someone looks at answers and makes an assessment, and you should not be charged for that.”

Beyond the confusion of being charged for what she thought would be free preventive care, Rogers wondered how the bill was calculated: Her conversation with her doctor about depression did not last that long, she said.

A 20- to 29-minute-visit billing code is commonly used in primary care, reflecting not just the time spent, but also the complexity of the condition or diagnosis, said Yalda Jabbarpour, a family physician in Washington, D.C. She also directs the Robert Graham Center for Policy Studies, which researches primary care in the U.S.

Billing codes exist for other, shorter time frames, though those are rarely used except for the most minimal of services, such as a quick question about a test result, she said.

Physicians said Rogers did the right thing, emphasizing that patients should be honest with their doctors during preventive visits — and not keep silent about issues because they are concerned about potential cost sharing.

“If you have a condition like depression, not only does it affect mental health, but it can have significant impact on your medical health overall,” said Stephen Gillaspy, senior director for health and health care financing at the American Psychological Association.

The Resolution: Confused by getting billed for a visit she thought would have no charge, Rogers initially called her doctor’s office and spoke with the office manager, who told her the claim submitted to her insurer was coded correctly for her visit. She then called her insurer to question whether a mistake had been made. She said her insurer said no, agreeing that the physician had billed properly.

Rogers paid the bill.

After being contacted by KFF Health News, and with Rogers’ permission, the WakeMed health system investigated the bill and said it was handled correctly.

“We do split bills when a service is provided that is above and beyond the preventive components of a physical — in this case, beyond a positive screening for depression,” WakeMed spokesperson Kristin Kelly said in an email.

By contrast, Cigna Healthcare, Rogers’ insurer, sent her a new explanation of benefits statement after being contacted by KFF Health News. The EOB showed Cigna had zeroed out any cost to Rogers associated with the visit.

Cigna spokesperson Meaghan MacDonald, in a written statement, said the “wellness visit was initially billed incorrectly with two separate visit codes, and has now been resubmitted correctly so there is no cost-share for Ms. Rogers. We are working with the physician to ensure she is refunded appropriately.”

The insurer’s website says Cigna covers a variety of preventive services without copayment and encourages doctors to counsel patients about depression.

Not long after receiving the new EOB, Rogers said she received a refund of $67.07 from WakeMed.

The Takeaway: While many preventive services are covered under the ACA, the nuances of when a patient pays can be complicated and open to interpretation. So, it is not uncommon for medical practices to narrowly interpret the term “preventive service.”

That creates a billing minefield for patients. If you respond on a questionnaire that you sometimes experience heartburn or headaches, most physicians will inquire about your responses to assess the need for treatment. But should that come with an extra charge? Other patients have written to KFF Health News and NPR expressing frustration over being billed for conversations during a checkup.

Additional time spent during a wellness exam discussing or diagnosing a condition or prescribing medication can be considered beyond preventive care and result in separate charges. But if you receive a bill for a preventive service that you expected would be free, request an itemized bill with billing codes. If something seems off, ask the physician’s office.

If you’re billed for time spent on extra consultation, question it. You know how long the provider spent discussing your health issue better than a billing representative does. Next, reach out to your insurer to protest.

Most important, be honest with your primary care provider during your annual physical.

Stephanie O’Neill reported the audio story.

Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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