Some people see January as a time to become the teetotaling, journaling, meal-prepping gym buffs they forgot to be last year. Other people choose resolutions they know they can achieve, like getting an early start on preventive care appointments. Simple enough — except the meaning of “preventive care” isn’t always clear. It can be confusing to navigate the preventive care guidelines issued by organizations such as the American College of Obstetrics and Gynecology (ACOG) or the American Cancer Society (ACS), not to mention figure out what insurance actually covers.
Alina Salganicoff, a vice president and director at the Kaiser Family Foundation, filled us in on what patients should know about preventive care to get the wellness exams and screening tests they need without running into unexpected medical bills.
What is preventive care?
Preventive care means medical services that focus on preventing disease and evaluating a patient’s current state of health. Examples include annual well-woman visits, most immunizations, and screening tests such as mammograms. The Affordable Care Act requires private insurance plans to cover recommended preventive services without imposing cost-sharing (e.g., copayments and coinsurance) on patients receiving them. This ACA requirement applies to all private insurance plans except for those with “grandfathered” status. To earn grandfathered status, a plan must have been purchased before March 23, 2010, the date the ACA was signed into law. Grandfathered plans are also prohibited from making significant changes to coverage, such as increasing patient cost-sharing, cutting plan benefits or reducing employer contributions. An insurance plan is required to disclose whether it has grandfathered status.
What qualifies as a covered preventive service under the ACA?
You might be familiar with preventive care recommendations issued by medical organizations such as the American Academy of Family Physicians or the American Academy of Pediatrics. But, as Salganicoff explains, it’s important to distinguish between preventive services that are recommended by professional organizations and those that have the power of law under the ACA’s preventive services benefit. “When an organization like the ACOG [American College of Obstetricians and Gynecologists] issues preventive care recommendations,” she says, “those guidelines are aimed at practitioners and have no force for purposes of insurance coverage.” Instead, in order to qualify as a covered preventive service under the ACA, the service must be recommended by one of four expert medical and scientific bodies:
- The US Preventive Services Task Force: The USPSTF is an independent volunteer panel of national experts in disease prevention and evidence-based medicine. Insurance plans must cover any services for adults that have an “A” or “B” rating from the task force. A full list of all preventive services with an “A” or “B” rating is available on the USPSTF website.
- The Advisory Committee on Immunization Practices: The ACIP is a federal committee composed of medical and public health experts, convened by the Centers for Disease Control and Prevention to develop recommendations for vaccine usage. The guidelines issued by the ACIP address immunizations for both adults and children, including those for the flu, meningitis, tetanus, and hepatitis A and B. A complete list of ACIP-recommended immunizations can be found here.
- The Health Resources and Services Administration’s Bright Futures Project: The Bright Futures Project provides recommendations relating to the health and wellbeing of infants, children and teenagers. The preventive services covered under the ACA for these groups include immunizations, behavioral and developmental assessments, and screenings for autism, vision impairment, tuberculosis and certain genetic diseases. A complete list of the current services recommended by the Bright Futures Project and covered under the ACA can be found here.
- The HRSA Women’s Preventive Services Initiative: In addition to coordinating the Bright Futures Project, the HRSA also issues guidelines for preventive services for women. In 2011, the HRSA adopted recommendations proposed by a committee from the Institute of Medicine. In 2016, the HRSA awarded a contract to ACOG to develop recommendations, and from that agreement the Women’s Preventive Services Initiative was created. The current preventive care recommendations for women include screening for cervical cancer beginning at age 21, mammography screening beginning at age 40 (for women with an average risk of breast cancer) and an annual well-woman exam. Here’s a full list of current recommendations for women.
How do insurance plans translate preventive care recommendations into coverage?
The requirement to cover preventive services recommended by the USPSTF, the ACIP and the Bright Futures Project took effect Sept. 23, 2010 for all non-grandfathered plans beginning on or after that date. The requirement to cover women’s preventive services affected plans beginning on or after Aug. 1, 2012.
When new or updated recommendations are issued by one of the four expert panels, insurance plans are required to cover those recommendations without cost-sharing. This coverage takes effect in the plan year that begins on or after exactly one year from the latest issue date. If the USPSTF issues a new recommendation on February 28, 2019, for example, insurance plans are required to update coverage accordingly on January 1, 2020. If a recommendation changes during a plan year, an insurance provider doesn’t have to change coverage in the middle of the year, unless a service is being discouraged because it was deemed harmful or poses a significant safety concern.
In addition, the Departments of Health and Human Services, Labor and Treasury jointly issue memos on how to implement portions of the ACA that require additional clarification on aspects of coverage for preventive care. (The most recent memos posted are from 2017.)
How do the ACA’s Essential Health Benefits relate to preventive care?
All insurance plans offered through Healthcare.gov (also referred to as the “marketplace”) must include what are known as the 10 Essential Health Benefits. This ACA provision is actually where the preventive services requirement arises from.
The list of required health benefits includes preventive services, as well as other types of care:
- Ambulatory patient services (another term for outpatient care)
- Emergency services
- Pregnancy, maternity and newborn care (before and after childbirth)
- Mental health and substance-use disorder services
- Prescription drugs
- Rehabilitative and habilitative services and devices
- Laboratory services
- Preventive and wellness services and chronic disease management
- Pediatric services, including dental and vision care
Don’t assume that ACA rules for preventive care apply to all services on this list. For instance, you still might incur out-of-pocket costs for some other Essential Health Benefits.
What about Medicaid patients?
Medicaid coverage for preventive services, Salganicoff explained, depends on whether someone has a traditional Medicaid plan or an expansion Medicaid plan.
The ACA expanded Medicaid eligibility to people with annual incomes below 138 percent of the federal poverty level. The ACA refers to the benefits offered under Medicaid expansion as an alternative benefit plan. An ABP must cover the 10 Essential Health Benefits (including preventive services).
However, states are not specifically required to cover preventive services for people with traditional Medicaid plans. In January 2013, the federal government began to offer states financial incentives to extend preventive care coverage to this population. If states include all of the adult preventive services recommended by the USPSTF and the ACIP in traditional Medicaid plans without imposing cost-sharing on patients, they can receive a one-percentage point increase in their federal Medicaid match rate (i.e., they get extra federal funding).
Although it might seem difficult to keep track of all of the different preventive services guidelines, Healthcare.gov maintains a comprehensive list of covered preventive services for adults, women and children.