Coverage of Preventive Services for Adults in Medicaid

Preventive services are intended for early diagnosis of health problems and for promoting healthy behaviors that can reduce the risk of developing chronic conditions. Medicaid programs across the country provide coverage to over 66 million low-income individuals, including nearly 33 million low-income children, 18 million adults, and 16 million elderly and people with disabilities.¹ The prevalence of chronic conditions tends to be higher among Medicaid beneficiaries compared to those with private insurance as well as those without any coverage; rates of diabetes, hypertension, and heart disease are at least twice as high among adults on Medicaid compared to low-income, uninsured adults.²

Preventive Services and the Affordable Care Act (ACA)

One of the goals of the ACA was to expand access to preventive services. One of the first requirements of the ACA to be implemented was to require virtually all private health plans to cover recommended preventive services without cost sharing beginning September 2010.³ Medicare also eliminated cost sharing requirements for all recommended preventive services starting January 1, 2013.⁴

Under Medicaid, states must cover preventive services for children, while coverage of preventive services for adults in Medicaid has historically been considered optional. Additionally, states have the option of instituting cost sharing for selected beneficiaries and selected services. Given their limited incomes and greater health care needs, federal rules limit the amount of cost-sharing states can charge Medicaid enrollees to help protect them from high out-of-pocket costs and facilitate their access to needed care. States are prohibited from charging any cost sharing for pregnant women as well as children and adults with incomes below the poverty level.

Box 1: Preventive Services for Adults The preventive services that are subject to the enhanced federal match for Medicaid are those that are recommended for adults by two entities: United States Preventive Services Task Force (USPSTF): USPSTF is housed at the Agency for Health and Research Quality (AHRQ) and develops recommendations for primary care clinicians and health systems after scientific evidence reviews of clinical preventive health care services; and Advisory Committee on Immunization Practices (ACIP): ACIP is housed at the Centers for Disease Control and Prevention (CDC) and develops recommendations for use of vaccines to control disease in the United States.5

One of the pillars of the ACA is the incentive for states to expand eligibility for Medicaid to cover many currently uninsured individuals. In states that expand eligibility (as of October 2014, 27 states and the District of Columbia have expanded), the benefits package for most adults in the new Medicaid expansion group is known as the “Alternative Benefit Plan” (ABP). Under the ABP, states must cover preventive services for adults without cost sharing, but this is not required for the group of adults enrolled in or eligible for traditional Medicaid prior to the ACA’s expansion of the program. However, in order to incentivize states to cover preventive services without cost sharing in traditional Medicaid, Section 4106 of the ACA added an enhanced matching rate of one percentage point to the state’s Federal Medical Assistance Percentage (FMAP) for preventive services if the state covers without cost sharing all of the preventive services recommended by the United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP) (Box 1).

In addition, Section 2713 of the ACA authorized the development of an additional set of preventive services for women, which were recommended by the Institute of Medicine (IOM) and subsequently adopted by the federal Health Resources and Services Administration (HRSA). These services must be covered without cost sharing by all new private plans. While these services are not included as part of the requirements for the Medicaid enhanced match for preventive services, they overlap with many of Medicaid’s benefits categories and were recommended as important to fill in gaps in preventive services for women.

This brief highlights data from a survey of state fee-for-service Medicaid programs conducted by the Kaiser Commission on Medicaid and the Uninsured (KCMU) on coverage and cost sharing for 47 preventive services recommended by the USPSTF, ACIP, and HRSA for non-elderly adults as of January 1, 2013.^6,7 In total, 39 states and the District of Columbia replied to the survey. Findings are summarized in the next section for coverage of cancer screenings, counseling on sexually transmitted infections, chronic conditions, health promotion, immunizations, pregnancy, and women’s health.