Preventive Services under the Affordable Care Act (Benefit Minute)
The Affordable Care Act (ACA) requires non-grandfathered group health plans and health insurance issuers to cover four broad categories of preventive services without cost-sharing. Since passage of the ACA, questions have emerged about the scope of certain required preventive services. Set forth below is a summary of the requirements and recent guidance addressing these questions.
Coverage of Preventive Services
Preventive services to be covered without cost-sharing include:
- Evidenced-based items or services that have an “A” or “B” rating from the United States Preventive Services Task Force (USPSTF) with respect to the individual involved, except for the USPSTF recommendation regarding breast cancer screening issued in 2009;
- Immunizations for routine use as recommended by the Advisory Committee on Immunization practices of the Centers for Disease Control and Prevention with respect to the individual involved;
- Preventive care and screenings for infants, children and adolescents included in guidelines supported by the Health Resources and Services Administration (HRSA); and
- Preventive care and screenings for women included in guidelines supported by the HRSA.
Preventive services must be covered without cost-sharing when performed by an in-network provider. If the plan does not have an in-network provider who can provide a particular service, then the service or item must be covered without cost-sharing for the out-of-network provider. If a recommendation or guideline does not specify the frequency, method, treatment or setting for a recommended preventive service, the plan or issuer may use reasonable medical management techniques to determine coverage limitations. When the required preventive service applies only to certain individuals identified as high risk, the decision regarding whether an individual is part of the high risk population should be made by the attending health care provider.
Clarification re: Specific Preventive Services
Aspirin and other over-the-counter medicines – must be covered without cost-sharing only for specified individuals and only when prescribed by a health care provider.
Genetic counseling and evaluation for breast cancer susceptibility gene (BRCA) testing – includes genetic counseling and the BRCA testing as determined by a woman’s health care provider. This coverage applies to women who have not been diagnosed with a BRCA-related cancer, including both those with a family history of cancers associated with an increased risk for breast cancer susceptibility genes and those with a personal history of cancer that was not BRCA-related.
Colon cancer screening – must be provided at no cost even if it results in the removal of a polyp during the procedure. In addition, the plan or issuer cannot impose cost-sharing for anesthesia services provided in connection with the preventive colonoscopy.
Breastfeeding counseling – includes coverage of comprehensive lactation support and counseling and costs of renting or purchasing breastfeeding equipment for the duration of breastfeeding.
Breast cancer medications – must be provided at no cost to women who are at increased risk from breast cancer and at low risk for adverse medication effects.
Tobacco cessation interventions – includes screening for tobacco use and coverage for at least two tobacco cessation attempts per year for those who use tobacco products. Covering a cessation attempt includes four tobacco counseling sessions of at least 10 minutes each without prior authorization and all FDA-approved tobacco cessation medications (including both prescriptions and over-the-counter medications) for a 90-day treatment when prescribed by a health care provider.
Contraceptive methods – includes the full range of FDA-approved contraceptive methods including, but not limited to, surgical sterilization, barrier methods, hormonal methods and implanted devices. Plans and issuers must cover at least one form of contraception in each of the methods identified by the FDA (currently 18 methods). Within each method, the plan may use reasonable medical management techniques and may impose cost-sharing on some items to encourage use of other specific items or services within the chosen method. If a woman’s attending provider recommends a particular service or item based on medical necessity, the plan must cover that item or service without cost-sharing. Services relating to a man’s reproductive capacity are not within the scope of the required preventive services. This requirement does not apply to religious employers. In addition, nonprofit employers and closely-held for-profit employers with religious objections to providing contraceptive services may seek an accommodation whereby the contraceptive services are provided to female participants, but not directly through the plan.
Well-women preventive care for dependents – must provide the full range of required preventive services that are age and developmentally appropriate, including services related to pregnancy (such as preconception and prenatal care).
Sex-specific preventive services – must provide coverage for the recommended preventive services as determined by the attending provider regardless of the sex assigned at birth, gender identity or gender of the individual otherwise recorded by the plan or issuer.