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The Catalyst

Affordable Care Act and MUSC Health Plan

By Mikie Hayes
Public Relations

Internal Medicine’s Dr. Jeffrey Wong examines a patient during a preventive screening.  photo provided

Preventive care is the cornerstone of the Affordable Care Act and an integral part of the MUSC Health Plan. As the country endeavors to move from a culture of sick care to one of prevention, the ACA, often referred to as Obamacare, provides guidelines for tests, services and medications that are designed to promote health and prevent disease.

According to the National Institutes of Health, Americans have not received the preventive health care they needed to stay healthy or to avoid or delay the onset of disease, in many cases due to cost. Cost–sharing by way of deductibles, coinsurance and copayments has to date presented a financial challenge for some Americans and reduced the likelihood that they would avail themselves of preventive services, often waiting until they experience symptoms to seek medical help.

Statistics from the Centers for Disease Control and Prevention underscore the fact that chronic diseases like heart disease, stroke, cancer and diabetes, which are responsible for seven out of 10 deaths among Americans each year and account for 75 percent of the nation’s health care spending, are often preventable with screenings and proper lifestyle changes. 

With these statistics in mind, the ACA was designed to ensure prevention is affordable and accessible for most Americans by requiring health plans to cover preventive health care services and eliminate cost sharing when services are rendered by a network provider. This is true even if the yearly deductible hasn’t been met. 

The MUSC Health Plan is ACA compliant, and subscribers are eligible for many services that once required a copay or coinsurance, but no longer do. Mammograms, flu shots, breast pumps, and for adults over the age of 50, even screening colonoscopies are a few of the benefits and screenings offered through the MUSC plan.

In addition to the flu shot, 12 additional immunizations are covered under the new ACA guidelines, as well as several preventative medications. When filled as prescriptions, these medications will require no copay thus resulting in no out–of–pocket costs for patients of certain ages or with certain medical conditions. 

The list includes the following drug categories: smoking cessation products, aspirin, FDA approved contraceptives, iron supplementation, folic acid, oral fluoride and vitamin D.

Since the ACA took effect Jan. 1, appointments to see primary care doctors for these services have risen dramatically and so too has the confusion about what is and is not covered, as the insured and insurers work to understand the complexities of the new act.

The confusion often boils down to the difference between preventive and diagnostic care. Both play an essential role in the health of a patient, but sometimes the difference between the two isn’t clear.

Preventive care is intended to promote wellness and prevent illness.  When a patient undergoes a preventive exam, a physician will discuss a number of subjects that could include taking an aspirin to reduce the risk of a heart attack, the need to expend more calories through exercise, smoking cessation, depression, and the symptoms of high blood pressure. They will also schedule preventive screenings.

But if a patient already has a diagnosis, things can get murky.  For instance, if the patient has a history of elevated blood pressure and the exam results in a discussion about the patient’s condition or medications, that can generate an additional charge. The patient might think that lowering blood pressure constitutes trying to prevent a heart attack and it would be considered prevention, the insurance companies however consider it a diagnostic and not a preventive screening.

Diagnostic care involves the diagnosing or treatment of an existing medical problem which may require additional monitoring or screening. While many mammograms and colonoscopies are considered preventive and therefore included under the ACA, some can also be considered diagnostic, and not preventive, for instance, if the mammogram is to follow up on a lump or the colonoscopy to evaluate bleeding.

The same test or service can be preventive, diagnostic or routine chronic care (regular care based on a chronic health condition) and the cost for the service may change based on why it’s being done and how it’s defined. The following chart describes the difference in each category:

Blood Pressure    

  • Preventive Exam — A patient with no history of high blood pressure is screened for HBP.Diagnostic Exam — A person with risk factors for HBP visits the doctor because he or she is experiencing symptoms.
  • Routine Chronic Care — A person with a history of HBP has his/her blood pressure monitored to ensure the HBP medication is working.


  • Preventive Exam — A 40–year–old woman receives a routine mammogram to screen for breast cancer.   
  • Diagnostic Exam — A 40–year–old woman receives a mammogram to evaluate a lump.
  • Routine Chronic Care — A 40–year–old woman who had a lump removed from her breast two years ago for cancer goes in for a follow–up mammogram.

When it comes time to schedule a preventive care visit, a patient can avoid confusion and perhaps an additional bill by familiarizing himself with fully covered services.

“As a patient makes an appointment for a preventive exam, it is important that he or she understands what is covered under preventive care,” said Mark Lyles, chief strategic officer.  “We need to educate the patient so that in the event he or she plans to discuss, for instance, a preexisting diagnosis, current medical complaint or prescription refills during this exam, it is understood that by doing so, can result in a separate charge.”

If a service is considered diagnostic or routine chronic care, the patient’s typical copayment, coinsurance or deductibles apply.
“For example,” Lyles added, “if a parent with the MUSC Health Plan brought their baby in for a well-baby visit, and the doctor determined the baby also had an ear infection, the appointment went from a strictly preventive exam to one that included a diagnostic visit.”

Because an ear infection diagnosis was made it changed the information that is sent to the insurance company, which also changes the way the claim is processed. That can result in a patient being responsible for a copay, coinsurance or satisfying a deductible for the treatment portion of the visit.

The ACA guidelines are specific about what is offered as well as when and how often preventive tests and services should be rendered. If a patient has any questions, touching base with the insurance provider before an appointment is a good idea.

Financial counselor for MUSC East Copper Specialty Care, Katrina Lander, stresses that there is a concrete process in place that is based strictly on procedure and diagnosis codes that are entered into the medical record and sent to the insurance companies. “We bill for what was performed, not what is covered,” Lander said. “If something changes mid–visit during a preventive exam or screening, the insurance company makes the determination of what will be covered.”

Since the ACA went into effect, primary care doctors have struggled with how to manage their time during preventive visits when patients bring up myriad questions about chronic medical problems. If the discussion in a preventive exam turns to previously diagnosed conditions, the code for that signals the insurance company to pay for an “office visit,” which usually means a copay will be required from the patient.

In some cases, patients hope to avoid a separate medical visit and see the preventive exam as a way to discuss various subjects with their doctor. But doctors are under pressure to document every individual reference in the patient’s electronic medical record or suffer possible Medicare reimbursement cuts in the future. They have a legal obligation to document and bill accordingly.

The ambiguity can be awkward for both patient and care giver. Lyles said, “When planning a preventive care visit, a good rule of thumb to follow is if you have symptoms, it will almost always be considered diagnostic and you’ll most likely pay part of the bill.”

“We don’t want this to blindside patients,” Lyles continued, “and we are developing a letter that the patient will receive to inform them of what is covered during their preventive exam. It will be confusing at first while all Americans, including providers and patients, learn how to navigate this new health care frontier.”

Before an appointment, patients may be asked if they choose to have only the services performed that are included in the basic preventive exam or if they prefer for their provider to evaluate and manage their medical problems during the preventive exam. Those additional services would then be considered part of a separate office visit and billed accordingly. Already, many patients have chosen to combine their appointments for the sake of time.

According to Lyles, patients have been pleased with the screenings, services and medications fully covered under the ACA–compliant MUSC Health Plan as well as how quickly they’ve been able to schedule and visit their doctors.

Find the current list of government-recommended preventive services fully covered under the Affordable Care Act at

April 4, 2014

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