It was business as usual for Katherine Campbell. Well, for the most part. She says she was having trouble sleeping and more. “Having mood swings and just not feeling myself. And I’m at the age where perimenopause can start,” she told Action 9 attorney Jason Stoogenke.
She went to the doctor. She says they ran tests and ultimately agreed with her: perimenopause.
She has insurance. And she knows the Affordable Care Act says insurance has to cover all sorts of preventive care -- including several services related to women’s health. She assumed her care fell under that. “Then I get a bill for $2,000,” she said. “I was shocked. I, in a million years, would not have thought that normal lifecycle changes, anything involved in that, wouldn’t be considered preventative.”
As for her health, Campbell says her doctor upped her medicines. So she’s sleeping better, except for the bill.
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Her insurance -- Cigna Healthcare -- emailed Stoogenke, “The law distinguishes between preventive services... and diagnostic” ones. “Symptoms associated with perimenopause” may be on the “diagnostic” side. “Under current federal rules, those labs are typically billed as diagnostic -- not preventive.” That means you can end up with a bill “even when the goal is early identification and prevention of more serious health issues.” The company says that was the case here. Plus, Campbell hadn’t met her “deductible” yet.
Cigna’s full statement: “Preventive care is essential to protecting long-term health. Under the Affordable Care Act, many preventive services are covered at no cost to the patient, including recommended women’s health services such as annual visits and mammograms. What qualifies as preventive care is defined by federal clinical guidelines, including recommendations from the U.S. Preventive Services Task Force (USPSTF) and the Health Resources and Services Administration (HRSA), which issues guidelines specific to women’s preventive health. The law distinguishes between preventive services, which are provided to people without symptoms to prevent disease or detect conditions early, and diagnostic tests, which are used to evaluate symptoms or guide treatment decisions. Physician-ordered tests or services to evaluate ongoing symptoms or investigate a concern are generally considered diagnostic and may include out-of-pocket costs.
Perimenopause and menopause are significant and often misunderstood transitions that can involve a wide range of physical and emotional symptoms. Cigna Healthcare is committed to helping women get appropriate care, support, and treatment, and we work with health care providers, clients, and customers to improve awareness, education, and access to women’s health services.
Depending on plan design, Cigna Healthcare customers have coverage options that may include hormone therapy, pelvic floor therapy, nutritional counseling, and both in-person and virtual care. Through in-network options including specialty women’s health providers and virtual care providers such as MD Live, customers can access board certified physicians who are trained to recognize and manage perimenopause and menopause symptoms, helping women get timely care and avoid unnecessary delays.
The services Ms. Campbell received are classified as diagnostic rather than preventive. While they are covered under Ms. Campbell’s specific benefit plan, cost sharing applied because her deductible had not yet been met.
Symptoms associated with perimenopause may require diagnostic testing to rule out other conditions, such as thyroid disease or anemia. Under current federal rules, those labs are typically billed as diagnostic — not preventive — which can result in cost sharing even when the goal is early identification and prevention of more serious health issues. This reflects a limitation in how preventive care is defined under current federal rules and recommendations, rather than a lack of prioritization of women’s health."
Campbell’s doctor is with Atrium. That health system emailed Jason they’re committed “to helping people” by “offering guidance and support as they navigate the financial aspects of their health care.”
Atrium sent Action 9 a statement, saying: “We understand that the medical billing process can be complex and, at times, frustrating for patients. While federal and state law prohibits us from discussing the details of any potential patient’s care or billing, our commitment to helping people live well includes offering guidance and support as they navigate the financial aspects of their health care. If patients have questions or concerns about their bill, we encourage them to reach out directly to our billing services department.”
Stoogenke says:
- Yes, be proactive about your health. Don’t wait.
- But just because you’re ‘proactive’ doesn’t mean it’s ‘preventive’ care.
- Know what counts as ‘preventive.’ Cigna’s website explains this well (and it applies to all insurance companies, not just them). See below.
- Still not sure? Ask your insurance ahead of time.
- You may have to ask your provider how they code it.
Here’s what’s considered preventive care, according to the Affordable Care Act:
Annual check-up or wellness exam
This is when your Primary Care Provider (PCP) checks all areas of your well-being—both physical and mental health. Annual check-ups are covered once a year and can help detect any health concerns early before they become major medical problems.
Well-baby and well-child appointments
These are regular health check-ups for babies and children. They include weight and physical growth checks, vaccines (if needed), and development assessment. These typically occur at roughly the following ages: 1 to 7 days, 1 month, 2 months, 4 months, 6 months, 9 months, 12 months, 15 months, 18 months, 2 years, 2.5 years, and annually starting at 3 years old.
Flu shot
Flu shots are typically covered 100% every year under most health plans. These vaccines help protect you from certain strains of the flu virus as well as reduce hospitalizations.
Other vaccinations
Immunizations for certain diseases like chickenpox, HPV, measles, mumps, rubella, polio, and more are covered 100%. These are usually administered during childhood and include boosters as needed.
Mammogram
Mammograms are routine X-rays of breast tissue to check for any signs of breast cancer or other abnormalities. Mammograms are usually recommended every year starting at age 40 but may be recommended sooner if you have certain risk factors.1
Colonoscopy
This is a screening for colon and colorectal cancer. It’s typically done every 10 years starting at age 45 unless you have other risk factors.2 There are also at-home tests available for colorectal cancer screening which are covered at $0. If an at-home test is positive or abnormal, a colonoscopy will be needed. This is considered part of the screening and is covered as preventive care.
Other cancer screenings
These may include prostate, lung, and cervical cancer screenings.
Screenings for health conditions
These may include diabetes, depression, and osteoporosis.
Here’s what’s considered non-preventive Health Care, according to the Affordable Care Act:
Diagnostic tests and screenings: These are not routine tests and screenings. For example, if your radiologist finds something on your lung cancer screening and wants another, that would be considered diagnostic testing and not typically covered as preventive care.
Additional primary care visits: Most health plans will cover you for one annual check-up with your doctor. Other visits during the same calendar year will likely not be covered as preventive. For example, let’s say you have flu symptoms and need to see your doctor virtually or in person—that’s not a covered preventive care visit.
Specialist visits: Visits to a specialist (gastroenterologist, orthopedist, neurologist, podiatrist, etc.) for a particular problem are not covered as preventive care.
Alternative therapies: Therapies such as chiropractic, massage, acupuncture, and other alternative health services are not considered preventive care.
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