Jan 20, 2022 - Health

When you're charged a copay you shouldn't owe

A man wearing glasses and a coat stands in front of a house.

Peter Sacco fought with his health plan to clear a copay he should have never been charged. Photo: Peter Sacco

Patients who take pre-exposure prophylaxis (PrEP), a medication that prevents HIV, should not be paying anything out of pocket for the drug — or for any blood work or doctor visits associated with getting PrEP.

The big picture: The federal government specifically reminded health insurers last year to make sure those types of ancillary services for PrEP were free at the point of care, but some patients are getting hit with bills anyway.

Zoom in: Peter Sacco, 28, of Washington, D.C., has a prescription for generic Truvada, a PrEP medication.

  • Sacco buys health insurance from CareFirst, a Blue Cross Blue Shield plan, on D.C.'s Affordable Care Act marketplace.
  • Sacco pays nothing out of pocket for his PrEP prescription, but last year he was charged copays for clinic visits and lab work associated with monitoring his health for the prescription.

The bill: $130 — two $60 copays for doctor visits in May and November of 2021 and a combined copay worth $10 for lab work for both visits.

Context: The Affordable Care Act requires health insurers to cover all preventive services that receive an "A" or "B" grade from the U.S. Preventive Services Task Force for free.

  • PrEP has an "A" grade, and federal officials told insurers last year there should be no copays for "baseline and monitoring services" for PrEP as part of USPSTF's recommendation.
  • After learning about this, Sacco appealed CareFirst's copays electronically and via mail. Both appeals were denied, and the insurer never addressed his concerns about how the copays ran afoul of the ACA.

What they're saying: "Insurers should've been lowering barriers even without this guidance from the federal government," said Katie Keith, a health law expert at Georgetown University who has written about this issue. "I'm worried people aren't being protected."

  • "It frustrates me that I've gone through the work of learning about [no cost-sharing for PrEP-related services], and there's a lot of people who don't know about it and are just paying these copays," Sacco said. "The cost burden for me is not as bad, but it could be more for others."

The other side: Maria Tildon, a marketing and lobbying executive at CareFirst, would not comment on Sacco's case. But Tildon said the broader problem stemmed from doctors not coding PrEP visits as "preventive," even though insurers ultimately have the responsibility to ensure there is no cost-sharing.

  • "We're in the throes of developing and distributing a pretty aggressive communications campaign to our provider partners to make sure that as they offer this treatment, they know how to submit the claim," Tildon said.
  • Samuel Le Church, a primary care physician and certified medical coder in Georgia, said it is "probably accurate" that many doctors prescribing PrEP aren't coding the other services as preventive, but "to be fair, there are so many things that come up with insurers ... and there's only so much bandwidth physicians have."

The resolution: After Axios asked CareFirst about Sacco's case, and as Sacco filed an appeal with the D.C. Office of Health Care Ombudsman, CareFirst told Sacco that all copays he paid will be refunded.

  • Tildon added CareFirst is conducting a retrospective review to see if other members who take PrEP have paid for related services and are owed refunds: "We want our members to be billed appropriately."

This is part of Axios' series, Billed and Confused. Have you been hit with an unexpected medical bill? Maybe the overall medical billing experience left you feeling puzzled or upset? Email [email protected], so we can dig into what's happening. Note: this story was originally published on Jan. 20.

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