Under 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 members receiving these services.
The required preventive services are based on 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 the Institute of Medicine (IOM) committee on women’s clinical preventive services.
New or updated recommendations issued by these expert panels generally must be covered without cost-sharing beginning in the plan year that starts on or after one year from the latest issue date. HMAA reviews these resources annually in August and makes benefit plan updates effective the following January 1, unless earlier implementation is needed due to a significant safety concern. 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 for immunizations such as influenza, meningitis, tetanus, HPV, hepatitis A and B, measles, mumps, rubella, and varicella. For COVID-19 vaccines and boosters, full coverage is required 15 days after ACIP recommendation, regardless of whether the vaccine is under an emergency use authorization or fully approved by the FDA.
- 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 for children and adolescents and 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 and include 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 circumstances in which insurers may charge copayments or 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, insurers may charge members 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 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. Certain questions regarding coverage of preventive services are addressed in these Frequently Asked Questions.
- Colon cancer screening – Screening for colorectal cancer using colonoscopies has an “A” rating from the USPSTF, and 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 incorporate lactation support, counseling and equipment rental without cost-sharing, for as long as the woman is breastfeeding.
- Well-woman visits – Preventive services for women include coverage for at least one well-woman visit for adult women, including preconception and prenatal care. 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. Further, dependents including sons and daughters must also receive all preventive services coverage as applicable without cost-sharing, and dependent daughters must 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 – Women with a 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 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 appropriate and recommended by her provider. For women deemed high-risk for breast cancer and low-risk for adverse medication effects, USPSTF also recommends of chemo-preventive medications such as tamoxifen or raloxifene, which must be covered without cost-sharing.
- Special populations – Where recommendations for preventive services, counseling, and immunizations apply only to a certain population, such as “high-risk” individuals, it is up to the health care provider to determine whether a patient belongs to that population. An individual’s sex assigned at birth or gender identity 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 – Health plans must cover the full range of prescribed contraceptive methods for women 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 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. Health plans are required to have an accessible and timely “waiver” process for members who have a medical need for contraceptives otherwise subject to cost-sharing. In addition, federal rules specifically exempt or accommodate certain employers that believe the requirement violates their religious rights.