A key provision of the Affordable Care Act (ACA) is the requirement that private insurance plans cover recommended preventive services under ACA 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.
ACA Requirements for Coverage of Preventive Services
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 in the plan year that begins on or after exactly one year from the new recommendation’s issue date.5 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 fact sheet are covered without cost-sharing.
Read the full report here.
Contact Steven G. Cosby, MHSA, Group Health Insurance Broker and Agent with Cosby Insurance Group, with questions or to request more information and to schedule a healthcare plan evaluation, savings analysis or group plan solution for your company.
