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Interpreting the Affordable Care Act
Akkaziev: 'I just want to see if the law prevails.'
Akkaziev: 'I just want to see if the law prevails.'

For Jambul Akkaziev, it's not about the money.

Last April, he emailed his doctor requesting some basic tests for sexually transmitted diseases. His doctor ordered a series of tests - standard stuff for most adults - which he got at Dean Health's clinic on Fish Hatchery Road.

The new Affordable Care Act requires insurance companies to cover 100% of testing of some STDs - including HIV and syphilis - as preventative care.

Nevertheless, a few weeks later, Akkaziev got a bill from Dean Health. "I was shocked," says Akkaziev, a grad student and teaching assistant at the UW-Madison.

Rather than pay the 10% copay the insurance company is asking, Akkaziev read the Affordable Care Act, parts of which went into effect in January. It strengthened his resolve.

Dean was labeling the tests as "diagnostic," even though, as Akkaziev says, "I had no symptoms or complaints." His doctor agrees the tests were preventative, he says.

Later, Dean officials told Akkaziev the tests had to be part of an office visit in order to be covered as preventative care. Again, Akkaziev insists the law says no such thing.

Eventually, he took his complaint to the state's Office of the Commissioner of Insurance, which agreed with him. The OCI's Diane Dambach wrote to Dean on Sept. 21: "Our legal staff does not agree with your interpretation of the language in regulation and the apparent assumption that the prohibition on cost-sharing doesn't apply to the HIV screening test separate from an office visit."

Dambach asked Dean to respond within 10 days. J.P. Wieske, an OCI spokesman, says the office hasn't completed a review of the case yet, but adds, "We have to apply the law."

It's illegal for Dean Health to discuss anything about a patient's care. But asked to clarify its coverage, Dean spokesman Pete Thompson emailed Isthmus its policy: "HIV screenings are payable under the preventive benefit when performed in conjunction with an office visit."

When asked to respond to OCI's challenge to that interpretation, Thompson says, "Dean Health Plan can't use the pages of your paper to resolve questions around a specific case."

But, he adds, the OCI letter is a common exchange "between…regulators and insurance companies, as both organizations attempt to interpret and implement the federal health care reforms to ensure compliance."

Akkaziev is frustrated with Dean's justifications. "Company regulations don't have precedence over federal law," he says. "I just want to see if the law prevails. That's the major issue. My reading is they violate the federal law."

Bobby Peterson, executive director of ABC for Health, says, "This is one of the failings of the Affordable Care Act. You've got provisions like these that do not have a clear enforcement act."

OCI does have some power to "cajole," Peterson says, but Gov. Scott Walker's administration has made it clear it's opposed to the law.

"I give this guy a lot of credit for taking them on. People need to do that," Peterson adds. "These are issues we all could face at some point, and these entities need to have some accountability."

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