- On December 12, 2023
The Affordable Care Act (ACA) requires all non-grandfathered health plans and health insurance issuers to provide plan participants with access to certain preventive care services on a first-dollar basis. Plans and health insurance issuers cannot impose any cost-sharing on these services, which means no deductibles, co-payments, or co-insurance may apply.
The preventive care services that must be covered are divided into three categories: (1) services for all adults; (2) services for women; and (3) services for children. The ACA specifies that any services or care that have an A or B rating from the U.S. Preventive Services Task Force qualifies as covered preventive care for all adults.* For women, the federal Human Resources and Services Administration’s (HRSA) Women’s Preventive Services list is the standard, and for children, it is the HRSA Bright Futures Project and American Academy of Pediatrics’ Recommendations for Preventive Pediatric Health Care.
Each year, these recommendations change, and plans and issuers are expected to cover any new or adjusted recommendation within one year unless coverage needs to be immediate for safety or emergency purposes (such as coverage of the COVID-19 vaccine). Since preventive care recommendations can change or be updated at any point during the plan year, it is a best practice for plans to begin to cover all of the past year’s recommendations upon renewal.
The new preventive care recommendations made in 2023 that should be covered in 2024 include:
- Screening for anxiety disorders in adults, including pregnant and postpartum persons.
- Screening for major depressive disorder and suicide risk in adolescents aged 12 to 18 years.
- Screening for hypertensive disorders in pregnant persons with blood pressure measurements throughout pregnancy.
- Screening for latent tuberculosis infection in adults who are at increased risk.
- Expansion of the HIV screening recommendation for adolescents to extend the upper age limit to 21 years. So now the recommendation is to screen adolescents for HIV at least once between the ages of 15 and 21. Plans must also cover an HIV risk assessment and prevention education beginning at age 13.
- Updated guidelines on coverage of breastfeeding services and supplies, including adding coverage of double electric breast pumps.
- Coverage of pre-pregnancy, prenatal, postpartum, and interpregnancy well-woman visits.
- Counseling to prevent obesity in women aged 40 to 60 years with normal or overweight body mass index.
Employer plan sponsors should verify that plans will be covering these services on a first-dollar basis in 2024. It is particularly important that you confirm any self-funded plans that you work with have made the necessary adjustments to their claim procedures and plan designs for the year ahead. In addition, given that there were changes made to preventive care relative to pregnancy, employer plan sponsors should verify that even if a plan does not cover the pregnancy of a dependent, dependents who may be pregnant are able to access pregnancy preventive care services.
*There is a lawsuit pending in federal court, Braidwood Management Inc. v. Becerra, which challenges the coverage requirement for services recommended or updated by the U.S. Preventive Services Task Force (USPSTF) on or after September 10, 2010. While the initial district court ruling found the requirement unconstitutional, the federal government appealed, and the 5th Circuit Court of Appeals issued an administrative stay of the district court’s ruling. This means that the federal government can continue enforcing the preventive services requirement while the lawsuit works its way through the appeals process.