A key provision of the Affordable Care Act (ACA) is the requirement that private insurance plans cover recommended preventive services without any patient cost-sharing.1 Research has shown that evidence-based preventive services can save lives and improve health by identifying illnesses earlier, managing them more effectively, and treating them before they develop into more complicated, debilitating conditions, and that some services are also cost-effective.2 However, costs do prevent some individuals from obtaining preventive services (Figure 1). The coverage requirement aims to remove cost barriers.
Under Section 2713 of the 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.3 These requirements apply to all private plans – including individual, small group, large group, and self-insured plans in which employers contract administrative services to a third party payer – with the exception of those plans that maintain “grandfathered” status. In order to have been classified as “grandfathered,” plans must have been in existence prior to March 23, 2010, and cannot make significant changes to their coverage (for example, increasing patient cost-sharing, cutting benefits, or reducing employer contributions). In 2014, 26% of workers covered in employer sponsored plans were still in grandfathered plans,4 and it is expected that over time almost all plans will lose their grandfathered status.
The required preventive services come from recommendations made by four expert 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. The requirement that insurers cover preventive services recommended by the USPSTF, ACIP, and Bright Futures program went into effect for non-grandfathered plans with plan-years beginning on or after September 23, 2010. The coverage requirements for women’s clinical preventive services became effective for plans starting on or after August 1, 2012. 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.5 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.6 In these circumstances, federal guidance will be issued.7 Individual and small group plans in the new health insurance marketplaces are also required to cover an essential health benefit (EHB) package – in addition to the full range of preventive requirements described in this fact sheet. There is some crossover as several of the specific preventive services fall into the EHB categories. However, only preventive services recommended by one of the four groups discussed in this factsheet are covered without cost-sharing.
The ACA requires private plans to cover the following four broad categories of services for adults and children (summarized in Tables 1 and 2):
Insurers now must cover 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), an independent panel of clinicians and scientists commissioned by the Agency for Healthcare Research and Quality. An “A” or “B” letter grade indicates that the panel finds there is high certainty that the services have a substantial or moderate net benefit. The services required to be covered without cost-sharing 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 common health concerns. The issue date for a recommendation from USPTF is considered to be the last day of the month in which it is published or otherwise released.
Health plans must also provide coverage without cost-sharing for immunizations that are recommended and determined to be for routine use by the Advisory Committee on Immunization Practices (ACIP), a federal committee comprised of immunization experts that is convened by the Centers for Disease Control and Prevention. These guidelines require coverage for adults and children and include immunizations such as influenza, meningitis, tetanus, HPV, hepatitis A and B, measles, mumps, rubella, and varicella. An ACIP recommendation is considered to be issued on the date that it is adopted by the Director of the CDC.
The ACA requires that private plans cover without cost-sharing the preventive services recommended by the Health Resources and Services Administration’s (HRSA’s) Bright Futures Project, which provides evidence-informed recommendations to improve the health and wellbeing of infants, children, and adolescents. 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.
The recommendations issued by USPSTF, ACIP, and Bright Futures predate the ACA. In addition to these services, the ACA authorized the federal Health Resources and Services Administration (HRSA) to make additional coverage requirements for women. Based on recommendations by a committee of the Institute of Medicine (IOM),8 federal regulations require new private plans to cover additional preventive services without cost-sharing for women, including well-woman visits, all FDA-approved contraceptives and related services, broader screening and counseling for STIs and HIV, breastfeeding support and supplies, and domestic violence screening.
While the ACA aims to reduce the burden of cost and increase use of preventive services, there are certain rules that both plans and policy holders must follow. There are circumstances, however, under which insurers may charge copayments and use other forms of cost-sharing when paying for preventive services. These include:
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.10 While there is no formal regulatory definition or parameters for reasonable medical management, medical management techniques are typically used by plans to control cost and utilization of care or comparable drug use. For example, plans can impose limits on number of visits or tests if unspecified by a recommendation, cover only generics or selected brands of pharmaceuticals, or require prior authorization to acquire a preferred brand drug. If a plan makes any material modifications that would affect the content of the plan’s Summary of Benefits and Coverage (SBC) during the plan year, the plan must notify enrollees of the change at least 60 days before it takes effect.11
The combination of these caveats and limitations has resulted in many questions about how plans should implement the preventive services policy. In particular, 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 Affordable Care Act which provide additional clarification on different aspects of coverage of preventive services:
The federal HHS Assistant Secretary for Planning and Evaluation (ASPE) estimates that approximately 137 million people (55.6 million women, 53.5 million men, and 28.5 million children) have received no-cost coverage for preventive services since the policy went into effect.18 While the number of individuals who have gained coverage for no-cost preventive services is large, public awareness of the preventive services requirement is relatively low. In March 2014, three and half years after the rule took effect, less than half the population (43%) reported they were aware that the ACA eliminated out-of-pocket expenses for preventive services.19 As awareness of the benefit grows and the share of people in grandfathered plans reduces, very few privately insured individuals will have financial barriers to clinical preventive care. The big question remains: will this new benefit increase use of preventive services and, ultimately, what will be the law’s impact on the public’s health and health care costs.
Maciosek, Michael V. "Greater Use Of Preventive Services In U.S. Health Care Could Save Lives At Little Or No Cost." Health Affairs 29.9 (2010): 1656-660.
Note that the rules described in this fact sheet apply to private insurers, self-insured employer plans, and are separate from preventive requirements for public programs like Medicare or Medicaid.
Kaiser Family Foundation, Health Research and Educational Trust, Employer Health Benefits 2014 Annual Survey.
The final issue date for new or updated recommendations varies by recommending body. Recommendations are considered to be issued on the last day of the month on which the USPSTF publishes or releases the recommendation; recommendations from ACIP are considered issued on the date it is adopted by the Director of the CDC; and a recommendation or guideline supported by HRSA is considered to be issued on the date on which it is accepted by the Administrator of HRSA or, if applicable, adopted by the Secretary of HHS. Federal Register, Vol. 80, NO. 134, July 14, 2015.
These circumstances include downgrade of a USPSTF service from a rating of “A” or “B” to “D” (which means that USPTF has determined that there is strong evidence that there is no net benefit, or that the harms outweigh the benefits, and therefore discourages the use of this service), or a service is the subject of a safety recall or otherwise determined to pose a significant safety concern by a federal agency authorized to regulate that item or service.
Institute of Medicine, Clinical Preventive Services for Women: Closing the Gaps, July 19, 2011.
Centers for Medicare and Medicaid Services, Affordable Care Act Implementation FAQs – Set 26.
CMS/CCIIO, Affordable Care Act Implementation FAQ’s Set 12.
The ACA requires that all FDA-approved contraceptive methods and services, as prescribed by a clinician, must be covered without cost-sharing. At least one version of each method must be covered, including brand-name versions if no generic option is available. However, religious institutions defined as “houses of worship” are exempt from the requirement. Women covered by these plans do not receive contraceptive coverage. Religiously affiliated nonprofit organizations and closely held for profit employers that object to contraceptives are eligible for an accommodation, and do not have to pay for contraceptive coverage offered by their employer-sponsored plans. In these cases, the insurer or third party administrator of these plans must pay for the cost of coverage, assuring that women covered by these plans receive contraceptive coverage. For more information see “How Does Where You Work Affect Your Contraceptive Coverage?”
KFF, Kaiser Health Tracking Poll, March 2014.