Coverage of Preventive Services for Adults in Medicaid

Appendix A: ACA Section 4106 increase in FMAP for Coverage of Preventive Services in Medicaid

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 USPSTF and ACIP (Table A1).

To receive the enhanced match, states must cover all of these services without charging cost-sharing for any and file a State Plan Amendment (SPA) to their Medicaid plan. As of July 2014, eight (8) states had submitted preventive services SPAs: Four states had filed for SPAs at the time the survey was conducted in Spring 2013: California, New Hampshire, New Jersey, New York. Since the survey was fielded, an additional four states have obtained SPAs: Hawaii, Kentucky, Nevada, Ohio.

The incentive became effective January 1, 2013, and there is no time limit for states to submit a SPA for preventive services coverage. This option is available to all states, regardless of whether they implemented the Medicaid coverage expansion or not. On February 1, 2013, CMS issued a letter to State Medicaid Directors (SMD# 13-002) which provided details to states on the criteria for submitting a preventive services SPA.1 Specific requirements of the policy outlined in the letter include:

  • States must cover all the recommended preventive services and their administration without cost sharing
  • The FMAP increase applies only to the preventive services
  • States must ensure they have correct codes and modifiers for providers to be able to match services rendered to the USPSTF and ACIP recommendations
  • States should have financial monitoring procedures to ensure accuracy in claiming enhanced rate
  • If preventive service overlaps with other enhanced reimbursement rates (e.g. temporary increase for primary care services), the 1% FMAP enhancement for preventive services is available for base payment rate from July 1, 2009
  • Coverage without cost sharing must be applied to those in fee-for-service and managed care
  • To claim the enhanced rate in managed care, states make estimates prospectively based on historical data from managed care plans to the extent possible
  • States should have capacity to add/amend services as USPSTF and ACIP add new recommendations or change existing ones
  • For 2013, the incentive only applies to services provided by physicians but as of January 1, 2014, will apply to services provide by other licensed practitioners
Cancer-Related Services (Table 1)
Breast cancer preventive medication counseling Clinicians discuss chemoprevention with women at high risk for breast cancer and low risk for adverse effects of chemoprevention.
Breast cancer mammography* Screening mammography for women, with or without clinical breast examination, every 1-2 years for women aged 40 and older.
BRCA screening and counseling Genetic counseling and evaluation for BRCA testing for women whose family history is associated with an increased risk for deleterious mutations in BRCA1 or BRCA2 genes.
Cervical cancer screening For women who have been sexually active and have a cervix.
Colorectal cancer screening Using fecal occult blood testing, sigmoidoscopy, or colonoscopy starting at age 50 through 75.
STI screenings (Table 2)
Chlamydial infection screening For sexually active women age 24 and younger and older women who are at increased risk.
Gonorrhea screening For all sexually active women, if they are at increased risk.
HIV screening For all adolescents and adults at increased risk for HIV infection.
Syphilis screening For those at increased risk.
STI counseling High-intensity behavioral counseling to prevent STIs for sexually-active adolescents and adults at risk.
Chronic Condition-Related Services (Table 3)
Prophylactic aspirin For men age 45-79 years and women age 55-79 years, if potential benefit outweighs potential harm.
Blood pressure screening For adults aged 18 and older.
Cholesterol abnormalities screening Men aged 35+ and women aged 45+, and those younger at increased risk of coronary heart disease.
Depression screening Staff-assisted supports to assure accurate diagnosis, effective treatment and follow-up.
Diabetes screening Type 2 diabetes in asymptomatic adults with sustained blood pressure above 135/80 mm Hg.
Osteoporosis screening Routine screening for women aged 65+, age 60 for women at increased risk of such fractures.
Health Promotion (Table 4)
Healthy diet counseling Intensive behavioral dietary counseling, delivered by primary care clinicians or specialists, for those with hyperlipidemia and other risk factors for cardiovascular and diet-related chronic disease.
Obesity screening and counseling Screen all adults for obesity, offer intensive counseling and behavioral interventions to promote sustained weight loss for obese adults.
Tobacco use counseling and interventions Ask all adults about tobacco use and provide tobacco cessation interventions.
Alcohol Misuse Counseling Screening and behavioral counseling interventions in primary care settings.
Folic acid supplementation A daily supplement of 0.4 to 0.8 mg of folic acid for women planning or capable of pregnancy.
Immunizations (Tables 5A and 5B)
Tetanus-Diphtheria (Td)booster and Tetanus-Diphtheria-Pertussis (T-dap) 1 Td Booster every 10 years and a one-time dose of Tdap for those under age 64.
Human Papilloma Virus 3 doses for females age 26 and under.
Measles, Mumps, and Rubella 1 or 2 doses for those 19-49; 1 dose for those 50 and older if other risk factors are present.
Varicella 2 doses for those 19-49; 2 doses for those 50 and older if other risk factors are present.
Influenza 1 annual dose for those 19-49 if other risk factors are present; 1 annual dose for those 50+.
Pneumococcal 1 or 2 doses for those 19-64 if other risk factors are present; 1 dose for those 65 and older.
Hepatitis A 2 doses if other risk factors are present.
Hepatitis B 3 doses if other risk factors are present.
Meningococcal 1 or more doses if other risk factors are present.
Zoster For those 60 and older.
Pregnancy-Related Services (Tables 6A and 6B)
Chlamydial infection screening For all pregnant women age 24 and under and for older pregnant women at increased risk.
Gonorrhea screening For all sexually active women if they are at increased risk.
Hepatitis B screening For pregnant women at their first prenatal visit.
Syphilis screening For all pregnant women.
Alcohol misuse counseling Screening and behavioral counseling interventions to reduce misuse in primary care settings.
Anemia screening For iron deficiency anemia in asymptomatic pregnant women.
Bacteriuria screening For asymptomatic bacteriuria with urine culture at 12 to 16 weeks gestation.
Breastfeeding counseling Interventions during pregnancy and after birth to promote and support breastfeeding.
Rh incompatibility screening at first visit Rh (D) blood typing and antibody testing for all pregnant women during first pregnancy-related visit; repeat for all unsensitized Rh(D) negative women at 24-48 wks unless biological father is Rh(D) negative.
NOTES: *HHS uses the 2002 recommendation on breast cancer screening. Survey is based on recommendations from the USPSTF related the ACA provision – and the Advisory Committee on Immunization Practices recommendations for adults in 2013 –
SOURCE: KCMU Survey of State Medicaid Coverage of Adult Preventive Services, 2013.

In addition to the services recommended by USPSTF and ACIP, Section 2713 of the ACA authorized the development of an additional set of preventive services for women, to be covered by private insurance plans. A committee of the Institute of Medicine (IOM) developed a set of recommendations for 8 preventive services for women, and these recommendations were subsequently adopted by the federal Health Resources and Services Administration (HRSA), which means that these services must be covered without cost sharing by all new private plans. These services (Table A2) are not included as part of the requirements for the Medicaid enhanced match for preventive services, but they overlap with many of Medicaid’s benefits categories and thus were included in this state-level survey.

Additional Preventive Services (Tables 7A and 7B)
Routine HIV Screening for Adults HIV screening for adolescents and adults ages 15-65. Younger adolescents and older adults at increased risk should also be screened.
HIV Screening for Pregnant Women Screening for all pregnant women, including those who present in labor whose HIV status is unknown.
Gestational Diabetes In pregnant women between 24 and 28 weeks of gestation and at the first prenatal visit for pregnant women identified to be at high risk for diabetes.
Well Woman Visit Well-women preventive care visit annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care.
Breastfeeding support, supplies, and counseling Comprehensive lactation support and counseling, by a trained provider during pregnancy and/or in the postpartum period, and costs for renting breastfeeding equipment.
Human papillomavirus testing (DNA) High-risk human papillomavirus DNA testing in women with normal cytology results. Screening should begin at 30 years of age and should occur nomore frequently than every 3 years.
Screening and counseling for interpersonal and domestic violence Annual screening and counseling for interpersonal and domestic violence for all women.
NOTES: HIV screening services were included in the survey and are discussed in a separate report:  Recommendations for all other services in this table are from HRSA Women’s Preventive Services.
SOURCE: KCMU Survey of State Medicaid Coverage of Adult Preventive Services, 2013.

Appendix B: Survey Instrument

Kaiser Commission on Medicaid and the Uninsured: Preventive Services Survey

This survey is intended to provide information that is helpful to Medicaid programs as well as the broader policy community about the role Medicaid in the provision of preventive services. Given that preventive services for children are covered under the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) benefit for children, this survey is designed to gather information on preventive services coverage in Medicaid programs for nonelderly adults. This survey was first conducted two years ago by Health Management Associates as part of the biannual update of the Kaiser Commission on Medicaid and the Uninsured Medicaid Benefits Database. The survey report is on the Kaiser Family Foundation web site at:

The revised instrument takes into account the guidance released in the February 1, 2013 State Medicaid Director letter on the option newly available to states under the ACA (Section 4106), effective January 1, 2013, to receive an enhanced federal matching rate for clinical preventive services and immunizations for nonelderly adults if they provide all of these services without cost-sharing. Specifically, states that cover all preventive services rated Grade A or B by the United States Preventive Services Task Force (USPSTF) and immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) without cost-sharing will receive a one percentage point increase in the federal matching rate for those services.

The CMS guidance cited above specifies that the one percentage point increase applies to preventive services and immunizations currently matched at:2

  1. the regular matching rate for states and the District of Columbia (without regard to the temporary enhanced match for specified primary care codes under ACA section 1202); or
  2. the enhanced matching rate under the Breast and Cervical Cancer Treatment Program.

The one percentage point increase does not apply to preventive services currently matched at other enhanced matching rates, most notably family planning services. In order for states to collect this one percentage point increase in the federal matching rate, states must submit a state plan amendment (SPA) to CMS and report such expenditures on a separate line of their CMS-64 forms.

The following suggestions may be helpful as you and your staff complete this survey:

  1. If your state has already submitted or is about to submit a SPA under this provision, please check “Yes” on the first question (provide an effective date if possible) and skip to Section III.
  2. Responses can be entered in any shaded area.
  3. To move around the form, you can use the tab key to move forward, shift-tab to move backward, or click any shaded area.
  4. To make an X in a check box, tab to the box and left-click on the mouse, or hit the space bar. Clicking the mouse or hitting the space bar a second time will remove a check. You can tab past the box if a check is not required.
  5. Text of any length can be entered in a text box. To start a new line within a text box, hold down the shift key and press return.
Appendix B: Survey Instrument
Survey Findings

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