By Kelsey Waddill
– There are four types of services that private payers and employers are required to cover under the Affordable Care Act (ACA) Preventive Care Services Provision, which include screenings and vaccinations, according to a fact sheet from Kaiser Family Foundation (KFF).
Under the ACA, payers must cover these services without cost sharing:
- Screening and counseling
- routine immunisations
- Prevention services for women
- Prevention services for children and young people
“These requirements apply to all private plans, fully insured and self-insured plans in the individual, small group and large group markets, except those that maintain ‘grandparent’ status,” the factsheet explains.
“Individual and small group plans in the health insurance markets are also required to cover an essential health benefits package (EHB), which includes the full range of preventive requirements described in this fact sheet.”
Payers must cover screening and counseling requirements based on USPSTF recommendations. Screening and counseling recommendations receiving an A or B rating should be fully covered.
At the time this article was published, the USPTF was recommending screenings for conditions such as sexually transmitted infections, depression, obesity, diabetes, prenatal testing, breast cancer and heart disease. The list included some of the most expensive chronic diseases in the United States.
The USPSTF has recommended counseling for drug and tobacco use and eating habits. These recommendations and those on screening may include age or gender factors that influence the level of assessment.
For example, USPSTF encourages screening of children ages eight and older for anxiety. However, the task force did not acquire enough data to make a recommendation for children under the age of eight.
Payers must also cover routine immunizations as recommended by the Advisory Committee on Immunization Practices (ACIP), a federal immunization committee. ACIP recommendations are finalized when they are adopted by the director of the Centers for Disease Control and Prevention (CDC).
As of May 2023, the immunization list covered conditions including, but not limited to, HPV, Hepatitis A and B, rubella, influenza, and tetanus.
The COVID-19 vaccine is also on the list, but operates under a different procedure than most immunization recommendations. Due to a waiver by Congress, the coronavirus vaccine and booster shot coverage requirement goes into effect 15 days after the CDC director adopts the recommendation.
The ACA rules on coverage of preventive care services for women are based on USPSTF and ACIP recommendations. But they also consider guidelines from the Health Resources and Services Administration (HRSA), which draw on the standards of the Women’s Preventive Services Initiative (WPSI).
To meet the requirements of preventive care services for women, taxpayers must fully cover visits to healthy women, breastfeeding support, screening and counseling related to intimate partner violence and other conditions and circumstances. Contraceptives that are approved, licensed, or licensed by the Food and Drug Administration (FDA) are also covered.
Overall, adults can access free cancer, chronic disease, health promotion, reproductive health and pregnancy services.
ACA preventive care coverage also includes services for children. These requirements are based on HRSA’s Bright Futures Project. They include visits of healthy children, vaccinations, screenings, developmental and behavioral assessments, and more.
Overall, the law requires taxpayers to fully cover preventive care services for children and youth related to infectious and chronic diseases, child development, adolescent sexual health, health promotion, and immunizations.
Comprehensive coverage for these services may be less ubiquitous if a legal challenge to this provision is successful.
In March 2023, a District Court judge ruled against the provision of preventive care services under the Affordable Care Act. Specifically, the judge ruled that it violated the religious freedoms of employers who did not want to cover preventive care services such as PrEP and contraceptives due to their personal beliefs.
Two months later, the U.S. Court of Appeals for the Fifth Circuit ruled that employers and health insurers must comply with the ACA’s Preventive Services provisions as the litigation continues.
#Categories #preventive #care #services #covered #ACA