FAQ - What are the ACA Preventive Care Rules?

Under the Affordable Care Act (also known as the ACA or Obamacare), group health plans must cover certain preventive services without any participant cost-sharing.

This provision is required under PHS 2713 and is often called the preventive care or preventive services requirement. This article outlines the ACA preventive care rules.

ACA Preventive Care Requirements

Section 2713 of the ACA requires private health plans to cover certain preventive care services without cost-sharing to participants in the form of copayments, deductibles, co-insurance, etc.

The preventive care requirements apply to all private, non-grandfathered group health plans, including:

• Individual health insurance policies

• Small group health insurance policies

• Large group health insurance policies

• Self-insured plans, including self-insured medical reimbursement plans

Related: Preventive Care and Employer Reimbursement of Health Insurance

List of Required Preventive Care Services

The required preventive care services are divided into three categories: adults, women (including pregnant women), and children.

Covered Preventive Services for Adults

1. Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked

2. Alcohol Misuse screening and counseling

3. Aspirin use for men and women of certain ages

4. Blood Pressure screening for all adults

5. Cholesterol screening for adults of certain ages or at higher risk

6. Colorectal Cancer screening for adults over 50

7. Depression screening for adults

8. Type 2 Diabetes screening for adults with high blood pressure

9. Diet counseling for adults at higher risk for chronic disease

10. HIV screening for all adults at higher risk

11. Immunization vaccines for adults--doses, recommended ages, and recommended populations vary:

12. Obesity screening and counseling for all adults

13. Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk

14. Tobacco Use screening for all adults and cessation interventions for tobacco users

15. Syphilis screening for all adults at higher risk

Covered Preventive Services for Women, Including Pregnant Women

1. Anemia screening on a routine basis for pregnant women

2. Bacteriuria urinary tract or other infection screening for pregnant women

3. BRCA counseling about genetic testing for women at higher risk

4. Breast Cancer Mammography screenings every 1 to 2 years for women over 40

5. Breast Cancer Chemoprevention counseling for women at higher risk

6. Breastfeeding comprehensive support and counseling from trained providers, as well as access to breastfeeding supplies, for pregnant and nursing women

7. Cervical Cancer screening for sexually active women

8. Chlamydia Infection screening for younger women and other women at higher risk

9. Contraception:  Food and Drug Administration-approved contraceptive methods, sterilization procedures, and patient education and counseling, as prescribed by a healthcare provider for women with reproductive capacity (not including abortifacient drugs). This does not apply to health plans sponsored by certain exempt “religious employers.”

10. Domestic and interpersonal violence screening and counseling for all women

11. Folic Acid supplements for women who may become pregnant

12. Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk of developing gestational diabetes

13. Gonorrhea screening for all women at higher risk

14. Hepatitis B screening for pregnant women at their first prenatal visit

15. Human Immunodeficiency Virus (HIV) screening and counseling for sexually active women

16. Human Papillomavirus (HPV) DNA Test

17. Osteoporosis screening for women over age 60 depending on risk factors

18. Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk

19. Tobacco Use screening and interventions for all women, and expanded counseling for pregnant tobacco users

20. Sexually Transmitted Infections (STI) counseling for sexually active women*

21. Syphilis screening for all pregnant women or other women at increased risk

22. Well-woman visits to obtain recommended preventive services*

Covered Preventive Services for Children

1. Alcohol and Drug Use assessments for adolescents

2. Autism screening for children at 18 and 24 months

3. Behavioral assessments for children of all ages

4. Blood Pressure screening for children

5. Cervical Dysplasia screening for sexually active females

6. Congenital Hypothyroidism screening for newborns

7. Depression screening for adolescents

8. Developmental screening for children under age 3, and surveillance throughout childhood

9. Dyslipidemia screening for children at higher risk of lipid disorders

10. Fluoride Chemoprevention supplements for children without fluoride in their water source

11. Gonorrhea preventive medication for the eyes of all newborns

12. Hearing screening for all newborns

13. Height, Weight and Body Mass Index measurements for children

14. Hematocrit or Hemoglobin screening for children

15. Hemoglobinopathies or sickle cell screening for newborns

16. HIV screening for adolescents at higher risk

17. Immunization vaccines for children from birth to age 18 —doses, recommended ages, and recommended populations vary

18. Iron supplements for children ages 6 to 12 months at risk for anemia

19. Lead screening for children at risk of exposure

20. Medical History for all children throughout development

21. Obesity screening and counseling

22. Oral Health risk assessment for young children

23. Phenylketonuria (PKU) screening for this genetic disorder in newborns

24. Sexually Transmitted Infection (STI) prevention counseling and screening for adolescents at higher risk

25. Tuberculin testing for children at higher risk of tuberculosis

26. Vision screening for all children

Source - HHS

Conclusion

The ACA requires all non-grandfathered group health plans to provide coverage for basic preventive care items and services without cost-sharing to the patient or participant. Employers and their advisors can use this guide to understand the preventive care requirements and to ensure compliance.

Additional Resources

• DOL and HHS FAQs on Preventive Care Requirements (May 11, 2015)

• KFF Slipsheet - Preventive Services Covered by Private Health Plans

• Preventive Care and Employer Reimbursement of Health Insurance

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