Flu shots should be free after health reform

Oct. 6--Editor's note: This column originally published Oct. 12, 2016, but the lessons still apply.

Advertisements for $5 flu shots this time of year really bug me.

I've been writing about health care reform -- and trying to put it in the simplest layman's terms for our readers -- since the Affordable Care Act (ACA), better known as Obamacare, took effect in March 2010. One key provision of the law, which I've pulled into many an info box, is this:

"Insurers must cover A- and B-level preventive services, such as screenings and immunizations recommended by the U.S. Preventive Services Task Force, with no co-payments or deductibles (if delivered by a provider in your plan's network)."

In other words, flu shots, annual physicals and annual screenings, including physicals with your family doctors, mammograms, Pap smears and colonoscopies, are supposed to be "free" with no copays or other costs for people with ACA-compliant insurance plans. And by now, pretty much all of us who are insured have compliant policies, whether through employer group plans or individual polices bought off or on healthcare.gov.

Just last week, I was ranting about the soaring costs of health insurance premiums and deductibles with a sorority sister who noted her company's group plan, once grandfathered in under pre-ACA laws, now must meet the new government standards that have resulted in higher monthly premiums.

"Grandfather died," she said. Funny.

What's not funny is the onus is on us consumers/patients to make sure we get the benefits promised in today's regulatory environment.

Case in point is what turned into a quest for my flu shot and that of my 15-year-old daughter, Jess.

Though our shared internist practices only two miles down the road, I didn't schedule the vaccinations through his clinic, thinking I'd avoid the hassle (ha!) and possibly being charged for doctors' office visits, when we simply needed to swing by somewhere and get our, um, quickie flu shots. So after picking up Jess after school last Wednesday, I drove directly to Walgreens where we regularly get our prescriptions filled. After some 15 minutes, and help from two pharmacy staffers, I was told Walgreens wasn't contracted by our insurance plan to administer the shots.

The next morning, I called Blue Cross Blue Shield of Oklahoma and, after speaking with two representatives, was transferred to a representative with St. Louis-based LDI, which handles my drug plan.

That gal wanted to refer me to the closest Walgreens until I told her about the previous night's fiasco. After a brief hold, she referred me to a nearby CVS Pharmacy.

So, Thursday night, I whisk Jess to CVS, where we stand -- and sit -- for more than 45 minutes. The staff inputted our information and got our injections ready. We signed the waivers and we were all set, until I noticed a $9 copay for each of us.

The intern/University of Central Oklahoma nursing student on our behalf called LDI, who ultimately told him a higher-up would have to make the decision -- though I'd received confirmation from the LDI customer service representative that very morning that my plan carried a zero copay on flu shots. Arghhh.

Overcoming glitch

After another call to LDI late Friday, we returned to CVS on Saturday to get our flu shots. A glitch in the system initially blocked the zero copay for a quadrivalent flu shot with added protection, a customer service rep explained on a message on my voicemail.

Back in the car on Thursday night, Jess made fun of how many times I mentioned Obamacare. I told her that I hoped I'd modeled good consumerism for her; that she should never pay $9 -- or, in the case of colonoscopies, hundreds more! -- that she didn't owe.

My parental lesson coincided with Jess wanting to cash in coins from my piggy banks for a trip to the mall on Friday. The kiosk at Walmart charged a 10.9% fee for cash, which I refused to pay, explaining to her that it would be throwing away hard-earned money, about $11 on every $100.

We settled instead for a no-fee gift certificate to Chili's, where we directly drove for dinner. Jess had macaroni and cheese and a pink lemonade, and I had fajitas and a well-deserved margarita.

Obamacare at a glance

Oklahomans can find assistance at: Localhelp.healthcare.gov or at 800-318-2596.

Enrollment opens Nov. 1 and runs through Jan. 15.

Consumers whose annual household incomes are between 100% and 400% of federal poverty (roughly $100,000 for a family of four) are eligible for subsidies.

The rates for the various ACA-compliant plans are the same whether they're bought through the exchange or directly from an insurance company. The only thing the exchange provides is access to potential premium subsidies.

Employers of 50 or more full-time equivalent must offer affordable, quality health insurance to workers who average 30 or more hours a week, or face annual penalties of $2,500 per employee. Businesses can face fines of $3,750 per employee for each worker who buys insurance on the exchange, if the company's insurance is deemed inadequate or unaffordable (costs more than 9.86% of a worker's salary).

Insurers can't deny coverage based on pre-existing conditions, and may not impose lifetime coverage limits.

Insurers must cover A- and B-level preventive services, such as screenings and immunizations recommended by the U.S. Preventive Services Task Force, with no copayments or deductibles. These services are only free if delivered by a provider in your plan's network.

Children who don't receive health care coverage from employers can stay on their parents' plans to age 26, regardless of marital or student status.

An 80/20 loss-ratio rule requires health insurers to spend no more than 20% of customer premiums on administration, or issue rebates to consumers.

Technically the requirement for individuals to have health insurance coverage still exist, but the penalty was lowered to $0.00 beginning in 2019 under the Tax Cuts and Jobs Act of 2017.

SOURCE: U.S. Department of Health and Human Services and Oklahoma Employee Benefits & Insurance, L.L.C. Updated Oct. 1, 2019.

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