Preventive Health Services Under
the Affordable Care Act:
Translating Law Into Coverage
Naomi Seiler, JD
Associate Research Professor
George Washington University School of Public Health
and Health Services, Department of Health Policy
Vitality Institute Health Promotion Forum
February 20, 2014
Coverage of Preventive Services
Section 2713 of the Affordable Care Act (ACA)
includes:
(1) Evidence-based items or services rated A or B
by the U.S. Preventive Services Task Force
(2) ACIP-recommended immunizations
(3) Preventive care for infants, children, and
adolescents recommended by HRSA,
(4) Additional preventive care and screenings for
women recommended by HRSA.
Covered Preventive Services for All Adults
(adapted from www.healthcare.gov)
• Abdominal Aortic Aneurysm one-time screening for men of specified ages who have
ever smoked
• Alcohol Misuse screening and counseling
• Aspirin use to prevent cardiovascular disease 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
• Diabetes (Type 2) screening for adults with high blood pressure
• Diet counseling for adults at higher risk for chronic disease
• HIV screening for everyone ages 15 to 65, and other ages at increased risk
• Immunization vaccines for adults--doses, recommended ages, and recommended
populations vary
• Obesity screening and counseling for all adults
• Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk
• Syphilis screening for all adults at higher risk
• Tobacco Use screening for all adults and cessation interventions for tobacco users
Covered Preventive Services for Women
(adapted from www.healthcare.gov)
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Anemia screening on a routine basis for pregnant women
Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer
Breast Cancer Mammography screenings every 1 to 2 years for women over 40
Breast Cancer Chemoprevention counseling for women at higher risk
Breastfeeding comprehensive support and counseling and access to breastfeeding supplies
Cervical Cancer screening for sexually active women
Chlamydia Infection screening for younger women and other women at higher risk
Contraception: Food and Drug Administration-approved contraceptive methods, sterilization,
counseling
Domestic and interpersonal violence screening and counseling for all women
Folic Acid supplements for women who may become pregnant
Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk
Gonorrhea screening for all women at higher risk
Hepatitis B screening for pregnant women at their first prenatal visit
HIV screening and counseling for sexually active women
Human Papillomavirus (HPV) DNA Test every 3 years for women 30 or olderwith normal cytology
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
Sexually Transmitted Infections counseling for sexually active women
Syphilis screening for all pregnant women or other women at increased risk
Tobacco Use screening and interventions for all women, expanded counseling for pregnant women
Urinary tract or other infection screening for pregnant women
Well-woman visits to get recommended services for women under 65
Covered Preventive Services for Children
(adapted from www.healthcare.gov)
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Autism screening
Behavioral assessments
Blood Pressure screening
Cervical Dysplasia screening
Depression screening
Developmental screening
Dyslipidemia screening
Fluoride Chemoprevention
supplements
Gonorrhea preventive medication
Hearing screening
Height, Weight and Body Mass Index
measurements
Hematocrit or Hemoglobin screening
Hemoglobinopathies or sickle cell
screening
HIV screening
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Hypothyroidism screening
Immunization vaccines
Iron supplements
Lead screening
Medical History
Obesity screening and counseling
Oral Health risk assessment
Phenylketonuria (PKU) screening
STI prevention counseling and
screening
• Tuberculin testing
• Vision screening
ACA: Many people will now
have access to these preventive
services without cost-sharing…
…but coverage varies
significantly by insurance type.
Coverage of Section 2713 Preventive Services:
Private Insurers
• All non-grandfathered private plans must cover
without cost-sharing
• Applies both inside and outside Exchanges
Coverage of Section 2713 Preventive Services:
Private Insurers (cont.)
Cost-Sharing for Preventive Service vs. Associated Office Visit:
• If preventive service billed separately from visit, may impose costsharing for the visit.
• If service not billed separately, and primary purpose is delivery of
that service, may not impose cost-sharing.
• If service not billed separately, and primary purpose is not delivery
of that service, the plan may not impose cost-sharing for the
preventive service but may impose cost-sharing for the visit.
• Plan may impose cost-sharing for any treatment that “results” from a
Section 2713 preventive service.
Coverage of Section 2713 Preventive Services:
Private Insurers (cont.)
Network v. Out-of-Network Providers:
 If a plan uses a network, not required to cover preventive
services out-of-network.
 If does cover preventive services out-of-network, may impose
cost-sharing.
 But if no in-network provider available to perform a
preventive service, the plan must cover the service when
offered by an out-of-network provider, and can’t impose costsharing.
Coverage of Section 2713 Preventive Services:
Private Insurers (cont.)
“Frequency, method, treatment, or setting”:
• If the USPSTF, ACIP, or HRSA recommendation or guideline
does not specify the “frequency, method, treatment, or setting”
for a preventive service, a plan may use “reasonable medical
management techniques” to apply coverage limitations.
• According to the preamble to the interim final rules, a plan
may “rely on established techniques and the relevant evidence
base” to establish such limitations.
Coverage of Section 2713 Preventive Services:
Medicare
• ACA does not require Medicare to cover
Section 2713 preventive services.
• If Medicare does cover any of the USPSTF- or
ACIP-recommended services, ACA requires
that it do so without any cost-sharing (note that
HRSA recommendations are not included
under these provisions).
Coverage of Section 2713 Preventive Services:
Medicare (cont.)
• However, Medicare does not have to follow
USPSTF’s recommendations on types of
provider or setting.
• Some Medicare preventive services are only
covered when offered by a primary care
provider in a primary care setting.
Coverage of Section 2713 Preventive Services:
“Traditional” Medicaid
• ACA incentivizes states to provide additional
preventive services to Medicaid beneficiaries
by providing an increase of 1% in the Federal
medical assistance percentage (FMAP) if a
state does provide coverage for all USPSTFor ACIP-recommended services and
immunizations.
Coverage of Section 2713 Preventive Services:
“Traditional” Medicaid (cont.)
• It appears that only a handful of states have
elected to cover all USPSTF and ACIP
services and receive the 1% FMAP boost.
• Lack of clarity on what services states are
covering in general.
• States now have the option of reimbursing
other state-certified providers for preventive
services (contrast to Medicare).
Coverage of Section 2713 Preventive Services:
“Expansion” Medicaid
• Under ACA and subsequent rules, all
Medicaid “expansion” plans must cover all
preventive services included under Section
2713, without any cost sharing.
So Where Does This Leave Us?
Efforts to Promote Awareness
• How do we communicate complex coverage
changes to patients?
• How do we communicate complex coverage
changes to providers?
Policy Change
• If assume no Congressional legislation is
imminent…
• Medicaid coverage policy decisions are now
largely at the state level
• How to convince states to cover all USPSTF
and ACIP services?
• Is there a way to broaden scope of Medicare
coverage?
Enforcement
• Like most of ACA, enforcement under private
plans is largely in the hands of state insurance
commissioners.
• Will this suffice with regard to coverage of
preventive services?
Research
• How are issuers interpreting the law and
guidance?
• Are providers getting appropriate
reimbursement?
• How does coverage intersect with bundled
payments?
• Is expanded coverage increasing uptake?
• Is increased uptake improving health?
Thank you.
Naomi Seiler
nseiler@gwu.edu