Under the Affordable Care Act (ACA), most health plans are now required to provide preventive services to their enrollees without any co-payments or other cost sharing.  Over time, this is expected to significantly improve prevention and wellness, reducing costs and reducing incidence of preventable condtions.  However, the preventive services manadate is complex. Here is a quick primer.

Three federal committees have the authority via the ACA to designate the specific preventive services that health plans must automatically cover:

1.  United States Preventive Services Task Force (USPSTF): USPSTF is panel of physicians and other primary care providers appointed by the Agency for Healthcare Research and Quality (AHRQ).  USPSTF evaluates the latest scientific evidence on clinical preventive services and rates preventive services based on their assessment of the evidence.

2.  Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC):  The ACIP advises on effective control of vaccine-preventable diseases and recommends vaccination schedules for children and adults.

3.  Secretary’s Advisory Committee on Heritable Disorders in Newborns and Children (SACHDNC) at the Health Resources Services Administration (HRSA):  SACHDNC advises on the most appropriate application of universal newborn screening tests, technologies, policies, guidelines, and standards for effectively reducing morbidity and mortality in newborns and children having, or at risk for, heritable disorders.

Overall, preventive services are currently utilized at 60% to 70% of recommended levels.

The mandate to cover federally designated preventive services and do so without any cost sharing applies to most health insurance plans in 2011, with the exception of grandfathered plans.

Impact of ACA Preventive Services Mandate on Utilization:

In a helpful health reform briefing paper, Milliman evaluates the changes to preventive care coverage in the US.  In Benchmarking Preventive Care Utilization, Milliman actuaries Ed Jhu and Jason Nowakowski highlight a series of problems health plans and actuaries will encouter in benchmarking, tracking, and complying with the ACA requirements on coverage of preventive services.

Preventive services are fluid and likely to change over time as they are based on recommendations and positions of the three advisory committees.  Also, there are several problems that may make setting preventive care benchmarks very difficult.  For example:

  • Not all data for preventive measures is easily captured.  Over-the-counter (OTC) medicine may not be submitted as an insurance claim.
  • Claim coding might come into play.  Some procedures may not currently be coded specifically as preventive, yet the service is de facto preventive.
  • Shifting demographics and the necessity for catch up.  For example, many individuals, particularly immigrants, may not have received vaccines as a child.
  • A number of the recommendations for preventive care involve patients considered at risk.  It may be difficult to define what the at risk population is and to determine how many people the label applies to.
  • It’s likely that some overuse of preventive services is occurring.
  • For plans that don’t cover preventive services, providers may bill non-preventive codes to get them paid.
  • Tests that begin as a screening may evolve into a diagnosis.  Many codes do not differentiate diagnostic services from screening services, making them difficult to identify, code, bill, and track.

Preventive Services That Must Be Covered by Health Plans:

Here are the preventive services currently endorsed by federal authorities. These are subject to change as the USPSTF, ACIP, and SACHDNC periodically update their recommendations.  Again, under the ACA, most health plans must cover these preventive services and do so without any cost sharing (e.g., no co-pay, no use of deductible).  To be exempt from cost sharing, preventive services must still be delivered by a provider in the health plan’s network.

Covered Preventive Services for Adults:

  • Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked
  • Alcohol Misuse screening and counseling
  • Aspirin use for men and women of certain ages
  • Blood Pressure screening for all adults
  • Cholesterol screening for adults of certain ages or at higher risk
  • Colorectal Cancer screening for adults over 50
  • Depression screening for adults
  • Type 2 Diabetes screening for adults with high blood pressure
  • Diet counseling for adults at higher risk for chronic disease
  • HIV screening for all adults at higher risk
  • Immunization vaccines for adults (doses, recommended ages, and recommended populations vary): Hepatitis A, Hepatitis B, Herpes Zoster, Human Papillomavirus, Influenza, Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Tetanus, Diphtheria, Pertussis, and Varicella
  • Obesity screening and counseling for all adults
  • Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
  • Tobacco Use screening for all adults and cessation interventions for tobacco users
  • Syphilis screening for all adults at higher risk

Covered Preventive Services for Women, Including Pregnant Women:

  • Anemia screening on a routine basis for pregnant women
  • Bacteriuria urinary tract or other infection screening for pregnant women
  • BRCA counseling about genetic testing for women at higher risk
  • Breast Cancer Mammography screenings every 1 to 2 years for women over 40
  • Breast Cancer Chemoprevention counseling for women at higher risk
  • Breast Feeding interventions to support and promote breast feeding
  • Cervical Cancer screening for sexually active women
  • Chlamydia Infection screening for younger women and other women at higher risk
  • Folic Acid supplements for women who may become pregnant
  • Gonorrhea screening for all women at higher risk
  • Hepatitis B screening for pregnant women at their first prenatal visit
  • Osteoporosis screening for women over age 60 depending on risk factors
  • Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk
  • Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users
  • Syphilis screening for all pregnant women or other women at increased risk

Covered Preventive Services for Children:

  • Alcohol and Drug Use assessments for adolescents
  • Autism screening for children at 18 and 24 months
  • Behavioral assessments for children of all ages
  • Blood Pressure screening for children
  • Cervical Dysplasia screening for sexually active females
  • Congenital Hypothyroidism screening for newborns
  • Depression screening for adolescents at higher risk
  • Developmental screening for children under age 3, and surveillance throughout childhood
  • Dyslipidemia screening for children at higher risk of lipid disorders
  • Fluoride Chemoprevention supplements for children without fluoride in their water source
  • Gonorrhea preventive medication for the eyes of all newborns
  • Hearing screening for all newborns
  • Height, Weight and Body Mass Index measurements for children
  • Hematocrit or Hemoglobin screening for children
  • Hemoglobinopathies or sickle cell screening for newborns
  • HIV screening for adolescents at higher risk
  • Immunization vaccines for children from birth to age 18 (doses, recommended ages, and recommended populations vary): Diphtheria, Tetanus, Pertussis, Haemophilus Influenza Type B, Hepatitis A, Hepatitis B, Human Papillomavirus, Inactivated Poliovirus, Influenza, Measles, Mumps, Rubella, Meningococcal, Pneumococcal, Rotavirus, and Varicella
  • Iron supplements for children ages 6 to 12 months at risk for anemia
  • Lead screening for children at risk of exposure
  • Medical History for all children throughout development
  • Obesity screening and counseling
  • Oral Health risk assessment for young children
  • Phenylketonuria (PKU) screening for this genetic disorder in newborns
  • Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk
  • Tuberculin testing for children at higher risk of tuberculosis
  • Vision screening for all children