Under Section 2713 of the Affordable Care Act (ACA), private health plans must provide coverage for a range of preventive services and may not impose cost-sharing (such as copayments, deductibles, or co-insurance) on patients receiving these services.
The required preventive services come from recommendations made by four medical and scientific bodies – the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP), the Health Resources and Services Administration’s (HRSA’s) Bright Futures Project, and HRSA and the Institute of Medicine (IOM) committee on women’s clinical preventive services.
New or updated recommendations issued by these expert panels are required to be covered without cost-sharing beginning in the plan year that begins on or after exactly one year from the latest issue date. If a recommendation is changed during a plan year, an issuer is not required to make changes mid-plan year, unless one of the recommending bodies determines that a service is discouraged because it is harmful or poses a significant safety concern. HMAA reviews these resources annually in August and makes benefit plan updates effective the following January 1. The references provided reflect information published as of the month of August.
Preventive Services for Adults and Children
- Evidence-Based Screenings and Counseling – Evidence-based services for adults that have a rating of “A” or “B” in the current recommendations of the United States Preventive Services Task Force (USPSTF) are covered without cost-sharing and include screening for depression, diabetes, cholesterol, obesity, various cancers, HIV and sexually transmitted infections (STIs), as well as counseling for drug and tobacco use, healthy eating, and other health concerns.
- Routine Immunizations – Immunizations for adults and children that are recommended and determined to be for routine use by the Advisory Committee on Immunization Practices (ACIP), are covered without cost-sharing and include coverage for adults and children and include immunizations such as influenza, meningitis, tetanus, HPV, hepatitis A and B, measles, mumps, rubella, and varicella.
- Preventive Services for Children and Youth – Preventive services recommended by the Health Resources and Services Administration’s (HRSA’s) Bright Futures Project, are covered without cost-sharing. The preventive services to be covered for children and adolescents include some of the immunization and screening services described in the previous two categories, behavioral and developmental assessments, iron and fluoride supplements, and screening for autism, vision impairment, lipid disorders, tuberculosis, and certain genetic diseases.
- Preventive Services for Women – Services recommended by the federal Health Resources and Services Administration (HRSA) as additional benefits for women are covered without cost-sharing including well-woman visits, all FDA-approved contraceptives and related services, broader screening and counseling for sexually transmitted infections (STIs) and HIV, breastfeeding support and supplies, and domestic violence screening.
Coverage Rules and FAQs
While the ACA aims to reduce the burden of cost and increase use of preventive services, there are certain rules that both plans and policyholders must follow. There are circumstances under which insurers may charge copayments and use other forms of cost-sharing when paying for preventive services. These include:
- If the office visit and the preventive service are billed separately, cost-sharing cannot be charged for the preventive service, but the insurer may still impose cost-sharing for the office visit itself.
- If the primary reason for the visit is not the preventive service, patients may have to pay for the office visit.
- If the service is performed by an out-of-network provider when an in-network provider is available to perform the preventive service, insurers may charge patients for the office visit and the preventive service. However, if an out-of-network provider is used because there is no in-network provider able to provide the service, then cost-sharing cannot be charged.
- If a treatment is given as the result of a recommended preventive service, but is not the recommended preventive service itself, cost-sharing may be charged.
The Public Health Service (PHS) Act and federal regulations also allow plans to use “reasonable medical management” techniques to determine the frequency, method, treatment, or setting for a preventive item or service to the extent it is not specified in a recommendation or guideline.
Questions have arisen about the frequency, range of methods that can be used for certain services, and the types of providers that are subject to the policy. The Departments of Health and Human Services, Labor, and Treasury jointly issue memos as Frequently Asked Questions specifically on implementation of the ACA which provide additional clarification on different aspects of coverage of preventive services:
- Colon cancer screening – Screening for colorectal cancer using colonoscopies receives an “A” rating from the USPSTF, yet there have been some cases of insured asymptomatic patients being charged unexpected cost-sharing for anesthesia and polyp removal during screening colonoscopies. The federal government has clarified that insurers cannot impose cost-sharing for medically necessary anesthesia services and polyp removal performed in connection with a preventive colonoscopy in asymptomatic individuals.
- Aspirin for the prevention of cardiovascular disease – Over-the-counter medications are provided without cost-sharing only with a prescription.
- Breastfeeding – While the USPSTF recommends prenatal and postnatal breastfeeding interventions, HRSA guidelines specifically incorporate lactation support, counseling and equipment rental without cost-sharing. Federally-issued FAQs clarified that this coverage should last as long as the woman is breastfeeding.
- Well-woman visits – The HRSA clinical preventive services for women include coverage for at least one well-woman preventive care visit for adult women, including preconception and prenatal care, yet controversy exists with the number of well-woman visits that are permitted per year. The government has clarified that multiple well-woman visits may be required to fulfill all necessary preventive services and should be provided without cost-sharing as needed, determined by clinical expertise. Federally issued guidance notes that all dependents, including sons and daughters, must also receive all preventive services coverage as applicable, without cost-sharing. The FAQs specifically outline that dependent daughters also receive preconception and prenatal care as part of a well-woman visit without cost-sharing.
- Testing and medications for the risk reduction of breast cancer – Federal guidance reinforces the USPSTF recommendation that women with family history of breast, ovarian, or peritoneal cancer should be screened for BRCA-related cancer, and those with positive results should receive genetic counseling and genetic BRCA testing when appropriate. As long as a woman has not specifically been diagnosed with BRCA-related cancer in the past, genetic screening, counseling and testing should be covered without cost-sharing when the services are medically appreciate and recommended by her provider. USPSTF also recommends the provision of chemo-preventive medications for women deemed to be at high risk. As such, risk-reducing medications, such as tamoxifen or raloxifene, must be covered without cost-sharing as prescribed to women who are at increased risk for breast cancer and at low risk for adverse medication effects.
- Special populations – In the cases where recommendations for preventive services, counseling, and immunizations apply only to a certain population, such as “high risk” individuals, the government clarified that it is up to the health care provider to determine whether a patient belongs to the population in consideration. An individual’s sex assigned at birth or gender identity also cannot limit them from a recommended preventive service that is medically appropriate for that individual; for example, a transgender man who has breast tissue or an intact cervix and meets other requirements for mammography or cervical cancer screening must receive those services without cost-sharing regardless of sex at birth.
- Contraceptive coverage – Federal clarification states that issuers and plans must cover the full range of prescribed contraceptive methods for women, currently at 18 distinct methods, as outlined in the FDA’s Birth Control Guide. Issuers may not limit coverage to any contraceptive method, such as oral contraceptives, but must provide at least one version of each FDA-approved contraceptive method without cost-sharing. Insurers may use reasonable medical management within a method, however, to limit coverage to generic drugs and can impose cost-sharing for equivalent branded drugs. Plans are required to have an accessible and timely “waiver” process for patients who have a medical need for contraceptives otherwise subject to cost-sharing. In addition, federal rules regarding contraceptive coverage specifically exempt or accommodate certain employers who believe the requirement violates their religious rights.