Preventive Health Services Requirements Under the ACA

The Affordable Care Act (ACA) requires Non-Grandfathered health plans to cover specific preventive services without any cost sharing requirements such as co-payments, coinsurance or deductibles. This provision became effective plan years beginning on or after September 23, 2010. The mandated preventive services are detailed on Department of Health and Human Services’ Web site created to explain health care reform details.

The mandated preventive services are based on three broad guidelines described under the ACA which references specific government organizations responsible for each set of guidelines.

      • Evidence-based items or services in the current recommendations of the United States Preventive Services Task Force that are graded A or B;
      • Immunizations for routine use in children, adolescents and adults that have in effect a recommendation from the Advisory Committee on Immunization Practices of the Centers for Disease Control and Prevention; and
      • Evidence-informed preventive care and screenings for (i) infants, children, and adolescents; and, (ii) women, as provided for in comprehensive guidelines supported by the Health Resources and Services Administration.

Services included in the preventive service mandate may change over time. Therefore, plan sponsors will be expected to review the website annually to keep up with these changes, and those changes would take effect beginning one year after the date the updated recommendation or guideline is issued. Plan sponsors do not have to cover items or services that are dropped from the list. Notices of these changes to employees may be required.

Guidelines for Coverage of Women’s Preventive Care

On August 1, 2011, the U.S. Department of Health and Human Services (HHS) announced that it was accepting the guidelines for women’s preventive care issued by the Institute of Medicine (IOM). These new guidelines are effective for Non-Grandfathered plans in the first plan year beginning on or after August 1, 2012. These requirements are outlined in this August 2011 Briefing, Coverage of Women’s Preventive Care.

Well-Woman Visits Well-woman preventive care visit annually for adult women to obtain the recommended preventive services that are age and developmentally appropriate, including preconception and prenatal care. This well-woman visit should, where appropriate, include other preventive services listed in this set of guidelines, as well as others referenced in section 2713. Annual, although HHS recognizes that several visits may be needed to obtain all necessary recommended preventive services, depending on a woman’s health status, health needs, and other risk factors.
Screening for Gestational Diabetes Screening for 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.
Human Papillomavirus Testing High-risk human papillomavirus DNA testing in women with normal cytology results. Screening should begin at 30 years of age and should occur no more frequently than every three (3) years.

Under the Patient Protection and Affordable Care Act (PPACA), non-grandfathered health plans must provide coverage for preventive services free of charge. As this change went into place for plan years beginning on or after September 23, 2010, most non-grandfathered plans have now implemented this change. The new guidelines will have to be incorporated into non-grandfathered plans in the first plan year that begins on or after August 1, 2012.
Counseling and Screening for Human Immunodeficiency Virus (HIV) Counseling and screening for human immunodeficiency virus infection for all sexually active women. Annual
Contraceptive Methods and Counseling. (see end note below) All Food and Drug Administration approved contraceptive methods, sterilization procedures, and patient education and counseling for all women with reproductive capacity. As prescribed.
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. In conjunction with each birth.

Group health plans sponsored by certain religious employers, and group health insurance coverage in connection with such plans, are exempt from the requirement to cover contraceptive services. A religious employer is one that: (1) has the inculcation of religious values as its purpose; (2) primarily employs persons who share its religious tenets; (3) primarily serves persons who share its religious tenets; and (4) is a non-profit organization under Internal Revenue Code section 6033(a)(1) and section 6033(a)(3)(A)(i) or (iii). 45 C.F.R.§147.130(a)(1)(iv)(B).

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