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Post date: March 11 2015

A.G. Schneiderman Announces Agreement With EmblemHealth To Boost Coverage For Preventive Services

Affordable Care Act Requires Expanded Access To Preventative Care Without Cost-Sharing For Patients

Enforcement Effort Will Remove Barriers To Patients Getting Preventative Colonoscopies, Provide Nearly $400,000 In Reimbursements To Patients

NEW YORK – Attorney General Eric T. Schneiderman today announced an agreement with EmblemHealth, Inc., requiring Emblem to cover anesthesiology services provided in connection with an in-network preventive colonoscopy, without any cost-sharing by the member. Emblem has also issued refunds to hundreds of Emblem members who paid a copayment, coinsurance, or deductible for such anesthesiology services.

An important provision of the Patient Protection and Affordable Care Act (“Affordable Care Act”) is the requirement that health plans cover recommended preventive services without member cost-sharing. Preventive services can improve health and save money by identifying health issues before they become complex and costly to manage. In order to encourage more individuals to seek these services, the Affordable Care Act requires free access to certain preventive services, without any cost-sharing requirements such as copayments, coinsurance and deductibles. One of these preventive services is in-network preventive colonoscopies.

“Preventative screening procedures are critical to improving the health of New Yorkers, and today’s agreement will help ensure that more people are getting important life-saving care,” said Attorney General Schneiderman. “My office will continue to verify that health insurance companies are following the law so that we can avoid the needless patient suffering and high-cost care involved with advanced illnesses.”

Because colonoscopies necessitate the administration of anesthesia, anesthesia services provided in connection with preventive colonoscopies should likewise be covered without member cost-sharing. In the past, only certain Emblem plans were structured to adhere to this principle, but even those plans failed to remove cost-sharing obligations for such anesthesia services. Now, Emblem has agreed to cover in full – without copayment, coinsurance, or deductible – all claims for anesthesiology services provided in connection with an Affordable Care Act-mandated in-network preventive colonoscopy.

As part of the agreement, Emblem has also sent reimbursement checks to members of certain Emblem plans whose claims for anesthesia performed in connection with an in-network preventive colonoscopy were processed subject to member cost-sharing. Reimbursements total close to $400,000. In addition, the agreement provides that Emblem will train its employees, and pay a penalty.

This settlement is the most recent of the Bureau’s efforts to ensure that health plans and providers are complying with the Affordable Care Act, and to educate consumers regarding the wide range of protections afforded them by the law. As a result of the Bureau’s past work, a health plan reinstated coverage for young adults who were not notified of their rights under the ACA, consumers received relief after their enrollment in an exchange plan was delayed, and refunds were provided to consumers who were wrongly charged co-payments for preventive services.

Consumers who believe they may have been treated unfairly by a health care provider, health plan, or health-related business should call the Attorney General’s Health Care Helpline at 800-428-9071.

The case was handled by Assistant Attorney General Carol Hunt of the Health Care Bureau. The Health Care Bureau is led by Bureau Chief Lisa Landau. The Health Care Bureau is a part of the Social Justice Division, which is led by Executive Deputy Attorney General Alvin Bragg.

A copy of the agreement can be read here.

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