Clinical Preventive Services Coverage and the Affordable Care Act

The Affordable Care Act requires many health plans to provide coverage for certain recommended clinical preventive services without charging copays or deductible payments. This provision could lead to greater uptake of many services that can improve health and save lives. Although the coverage provision is broad, there are many caveats that also apply. It is important for providers and public health professionals to understand the nuances of the coverage rules to help maximize their potential to improve population health.


ORGANIZATIONS PROVIDING GUIDELINES
The ACA ( §1001) 4 designated several organizations as the source for guidelines that identify the clinical preventive services and population groups that should receive coverage without copays or deductibles. The United States Preventive Services Task Force (USPSTF) and the Advisory Committee on Immunization Practices (ACIP) are long-standing organizations composed of health professionals that produce evidence-based recommendations for clinical services to prevent and control disease. The ACA recognizes services recommended by these organizations, along with those for women and children supported by the Health Resources and Services Administration (HRSA; see the box on page e3).
With respect to children, HRSA has endorsed the recommendations of the Bright Futures initiative from the American Academy of Pediatrics 5 and the Recommended Uniform Screening Panel of the Discretionary Advisory Committee on Heritable Disorders in Newborns and Children. 6 For women, HRSA supports the coverage guidelines recommended in the July 2011 Institute of Medicine report Clinical Preventive Services for Women. 7 The law requires nongrandfathered private plans to adopt new clinical guidelines from these organizations beginning with plan years starting 1 year after the date the recommendation is issued. 8

PRIVATE HEALTH PLANS
The ACA requires all private health plans to provide the full suite of preventive services with no copays or deductibles, unless the plan has grandfathered status. 8 Grandfathered plans that existed on or before March 23, 2010, and have continually met certain requirements are not required to cover any preventive care. 9 An individual plan in which the insured has been continuously covered since before March 23, 2010, may be grandfathered. Any group plan that existed before March 23, 2010, and has had at least 1 person enrolled at all times since that date may also be grandfathered. Grandfathered plans can lose that status by significantly reducing benefits; adding or tightening annual coverage limits; significantly raising coinsurance, copays, deductibles, or employee contributions; or not claiming grandfathered status in policy and benefits materials.
Worker enrollment in grandfathered employer-sponsored plans has already decreased from 56% of covered workers in 2011 to 26% in 2014. 10 The grandfathered proportion of non--employer-sponsored policies is not known. Over the next few years, if more individuals acquire insurance through the Health Insurance Marketplace-all Marketplace plans are nongrandfathered-and if more grandfathered plans are discontinued or lose their grandfathered status, an increasingly large percentage of the privately insured population will have coverage of preventive services without copays or deductibles.

MEDICARE
The ACA also reduces copays and deductibles for Medicare beneficiaries. Medicare provides certain office visits without copays or deductibles, including a Welcome to Medicare visit for new enrollees and the Annual Wellness Visit ( §4103). 4 These visits include discussions about recommended preventive care and a health risk assessment. Medicare also provides coverage without copays and deductibles for most USPSTF-recommended services and 3 vaccinations: influenza, hepatitis B, and pneumococcal.
The effects of these coverage provisions are already being felt. More than 37 million Medicare beneficiaries received 1 or more preventive services without paying a copay or deductible in 2013. 11 Although Medicare is not required to cover all the services recommended by the USPSTF, if Medicare provides coverage for a USPSTF-recommended service, it must be provided with no copays or deductibles ( §4104). 4 Approximately 1 in 6 Medicare beneficiaries are younger than 65 years, so Medicare coverage of preventive care recommended for nonseniors is important for millions of Medicare beneficiaries. 12 Only a small number of USPSTFrecommended services are not covered by Medicare, including genetic counseling and evaluation for high-risk breast cancer genetic testing and breastfeeding counseling. 13 Vaccinations other than influenza, hepatitis B, and pneumococcal may be available through Part D coverage and may be subject to copays or deductibles. Unlike nongrandfathered private plans, Medicare is also not required to cover services recommended by the ACIP or supported by HRSA ( §4104). 4

MEDICAID AND THE CHILDREN'S HEALTH INSURANCE PROGRAM
The ACA also calls for additional benefits for certain Medicaid and Children's Health Insurance Program beneficiaries. It is important to note that there are different types of Medicaid coverage. The first kind of coverage, for children, pregnant women, parents, seniors, and individuals with disabilities, preceded the ACA, and is often called "traditional" Medicaid. The ACA gives states the opportunity to expand Medicaid for individuals with an income up to 133% of the federal poverty level ( §2001). 4 Beneficiaries that are newly eligible for Medicaid through the expansion receive coverage through an alternative benefit plan that includes coverage without copays or deductibles for preventive services recommended by the USPSTF and ACIP and supported by HRSA-the same coverage required for nongrandfathered private plans. 14 Through traditional Medicaid and the Children's Health Insurance Program, children younger than 18 years receive free preventive care, including ACIP-recommended vaccinations, vision and dental services, screenings and examinations, and other necessary health care services through the Early and Periodic Screening, Diagnostic, and Treatment benefit. 15 With respect to adults, states must cover certain tobacco cessation services and pregnancy-related care without copays or deductibles ( §4107). 4 But with those exceptions, states are generally not required to cover preventive care for adult traditional Medicaid beneficiaries and may charge copays.
A recent analysis finds that only 6 of 47 states surveyed provided coverage without copays or deductibles to adult traditional Medicaid beneficiaries for all 42 preventive services examined. 16 States that cover without copays or deductibles all the preventive services recommended by the USPSTF and ACIP can receive a 1 percentage point increase in their Medicaid federal matching rate for those services ( §4106). 4 The bottom line is that children with traditional Medicaid or enrolled in the Children's Health Insurance Program and beneficiaries newly eligible for Medicaid through the expansion will have a full range of preventive services covered without copays or deductibles. Benefits for adults with traditional Medicaid will vary from state to state. In states that do not expand Medicaid, many lower-income individuals will go without access to affordable preventive services coverage.

IMPLEMENTATION OF COVERAGE REQUIREMENTS
Plans have some flexibility in how they implement the ACA's provisions. Many of the recommendations were originally written as evidence-based clinical practices and not insurance coverage rules, leaving plans to set reimbursement guidelines that comply with reasonable medical management practices and providers to exercise clinical judgment. Although subregulatory guidance has clarified the intention of some coverage rules (e.g., identification and removal of polyps during a preventive colonoscopy should be covered without copays or  18 For patients, the difference could be thousands of dollars-and perhaps a reluctance to pursue the appropriate follow-up care. 19 Providers also play an important role in securing full reimbursement for their patients without copays or deductibles. For example, many insurance plans have explicit billing requirements, such as billing with specific procedure and diagnosis codes for the service to be exempt from copays and deductibles. To avoid unnecessary bills for patients, providers will need to work with plans to be aware of billing and reimbursement rules and the coverage for preventive services for each patient. To help address these concerns, the Centers for Disease Control and Prevention has provided the CDC Prevention Checklist, a Web-and smartphone-based tool that helps patients and providers identify and understand the recommended preventive services and that includes billing information for some major insurers. 20 Realizing the potential of the ACA's preventive care provisions to improve population health may require, among other factors, an effective and coordinated alliance of political and technical leadership. 21 Public health can provide essential safety net services, an evidence base for interventions, and messaging to increase awareness of affordable access to important care. The Primary Care Information Project in New York City is an example of public health working in collaboration with providers, leading to increases in preventive care delivery and population health improvement. 22

Human Participant Protection
This article does not report data from human participants; therefore, no institutional review board approval was needed. Note. ACIP = Advisory Committee on Immunization Practices; BMI = body mass index (defined as weight in kilograms divided by the square of height in meters); FDA = Food and Drug Administration; HRSA = Health Resources and Services Administration; USPSTF = United States Preventive Services Task Force. The Affordable Care Act requires many insurance plans to cover these clinical preventive services in network without charging copayments or deductibles for beneficiaries who meet the clinical risk factor guidelines (age, gender, pregnancy status, disease status, etc.).