Jeff Cornett went to a Walgreens last week to get his free flu shot.
He was told there was a $15 co-pay.
Cornett, a nurse and patient advocate who lives in Stone Mountain, replied that he believed the shot was free.
He knew that under the health care reform law, members of health plans get several preventive care services such as flu shots free of charge if they go to network providers — and as long as their plans aren’t exempted, or ‘’grandfathered.’’
His employer plan had no such exemption, and Walgreens was a network pharmacy for his health insurer, Blue Cross and Blue Shield of Georgia.
Still, Cornett recalls, the pharmacist consulted her computer and told him again that he would need to pay the $15.
He paid the money and got the shot. But he didn’t let the matter go.
Health benefits generally are a confusing maze for most consumers. And the health reform law has injected another layer for patients to peel back in order to understand their coverage.
Passed in 2010, the law required health insurers to provide screenings — such as for blood pressure, cholesterol and depression — along with vaccinations, without any out-of-pocket cost to adults. Medicare beneficiaries also gained a range of free preventive services under the law, which is more officially known as the Affordable Care Act.
Many health plans, though, are exempt from that requirement because they were grandfathered in under the law if they didn’t make major benefit changes.
Returning from the pharmacy, Cornett called Blue Cross. He says he didn’t get anywhere with the first claims person he talked with, who told him he had a $15 co-pay.
So he asked to talk with a supervisor.
The supervisor, Cornett says, also said he had a co-pay. “She said the Affordable Care act was not about this – it was about something else,’’ he says.
But Cornett says that after he persisted, the supervisor did some checking. She later called him back and said the company had arranged for Walgreens to give him a refund.
When asked about Cornett’s problem, Blue Cross issued a statement agreeing that members of non-exempt plans have no co-pay for flu shots at the insurer’s network pharmacies.
“We understand some members have not been able to immediately access coverage for flu shots at pharmacies, and we are working diligently to understand the source of these issues and correct them immediately,’’ the statement said.
“In the meantime, [Blue Cross] members can always call the customer service number on the back of their card while they are at the pharmacy if experiencing any difficulties. If members paid for flu shots within the past seven days, they can have the pharmacy run the claim again and be reimbursed there. Members who paid for flu shots more than seven days ago can file a paper claim with [Blue Cross] for reimbursement.’’
Washington-based consumer advocacy group Families USA, a strong proponent of the reform law, says the legislation’s new preventive benefit will help improve the health of many Americans.
“But, with any kind of new benefit, there has been confusion among patients, providers, and insurers about what is covered and what isn’t,’’ says Michealle Gady, a health policy analyst with Families USA.
“Adding to this confusion is the complexity of our system, with multiple payers and many different rules and requirements.’’
Even some grandfathered-in health plans have free preventive care benefits, even though they don’t have the same requirement as non-exempt plans, experts say.
(Georgia and 25 other states are fighting the health care law in court, claiming it is unconstitutional, but meanwhile some of the law’s provision have already taken effect.)
The Georgia Association of Health Plans says it has not heard ‘‘a lot of issues’’ related to free preventive services. A representative of the state insurance commissioner’s office says it has received one complaint about flu shots.
That was presumably from Cornett, who says he complained to the agency.
But he says at least four of his co-workers have had to pay a co-pay when none was required.
Blue Cross spokeswoman Cheryl Monkhouse says the problem appears to be isolated to retail pharmacies.
Cornett went to Walgreens and picked up his refund, but he hasn’t put the issue behind him.
“I’m totally ticked off,’’ he says. “They’re continuing to charge co-pays when they’re not supposed to. I was really shocked that the Blue Cross claims people had no knowledge of the Affordable Care Act.’’
Cornett says $15 is not a huge amount for him, but it could be more of a hardship for people with low incomes. “I’m concerned that the problem is greater than flu shots,’’ he adds.
Gady, of Families USA, says insurers should educate providers and patients about the no-co-pay benefit and how it works.
And patients should always read their summary of benefits and understand what their plan does or does not cover, she says.
Georgia’s insurance department says that if consumers have questions about their preventive services benefits, they can contact the agency’s Consumer Services Division for assistance at 404-656-2070 or toll-free at 1-800-656-2298. The telephone hours are Monday through Friday from 8 a.m. to 7 p.m.
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