Preventive Healthcare Services and Coverage

An important and often overlooked benefit of the Affordable Care Act (ACA) is full coverage and benefits for preventive care.  Specifically, the ACA established that virtually all private health plans must provide 100% coverage (i.e., no cost share) for a host of preventive healthcare services.  The only exception to this requirement are so called “grandfathered” plans, which are becoming more scarce every year.  So in short, all non-grandfathered health insurance plans (i.e., individual, small group, large group, fully insured, and partially self-insured) may not require cost-sharing such as copays, deductibles, or coinsurance, for any of the listed preventive services, within the following broad categories:

  1. Evidence Based Screenings and Counseling
  2. Routine Immunizations
  3. Preventive Services for Children and Youth
  4. Preventive Services for Women
The list of required preventive services comes from four specific government bodies including:
  • The U.S. Preventive Services Task Force (USPSTF)
  • Advisory Committee on Immunization Practises (ACIP)
  • Health Resources and Services Administration (HRSA) and Bright Futures
  • Institute of Medicine (IOM)
Underscoring the importance of this benefit, and the need for people to seek preventive screening and care, is the fact that cost is often a real or perceived barrier in seeking preventive care.  The following data from the Kaiser Family Foundation captures the depth of this challenge by gender, income relative to federal poverty level (FPL), and insured status:

The list of covered preventive services has grown considerably since this aspect of the ACA went into effect for non-grandfathered plans beginning/renewing on or after September 23, 2010.  In 2012, specific “Women’s Preventive Services” were added, including some contraception drugs and devices.  Initially, some 38 specific preventive services were indicated on the list, and as recently as 2014, there were 63 distinct preventive services included.  Currently (2016/2017) there are 72.

Starting in late 2017/early 2018, the list of required covered preventive services increases to 98, and includes coverage for cholesterol screening and some statin drugs. So as health insurance plans begin renewing, and preventive care services grids are updated, expect to see certain statin drugs like Atorvastatin, Lovastatin, Simvastatin, and Pravastatin covered at a $0 cost-share, as early as the end of 2017The actual drug(s) and dosages covered without a cost-share will vary depending on the insurance company and coverage.

The USPSTF’s  new guidelines affecting cholesterol/lipid disorder screening lists the following criteria for obtaining no cost screenings and covered statin drugs, for patients with no prior history of cardiovascular disease:
  • Patient ages 40 – 75;
  • have one or more cardiovascular risk factors such as dyslipidemia, diabetes, hypertension, or smoking; and
  • have a calculated 10-year risk of a cardiovascular event of 10% or greater.

IMPORTANT: All insurance companies and plans provide a detailed grid outlining the covered preventive services for the particular plan year.  These grids can typically be found on employer, administrator, and/or insurance company web portals.

To access a comprehensive list of all covered preventive services by type, gender, frequency, click – https://www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

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