Research has shown that higher rates of use of preventive services can have a significant impact on individual health and the cost of health care. However, the cost of these services was a barrier for many insured and uninsured individuals. In response to this concern, one key provision of the ACA requires private insurance plans to cover preventive health care services without cost-sharing (copayments, coinsurance, or deductible) for patients. This requirement, established under Section 2713 of the ACA, applies to all private plans in the individual, small group, and large group markets, as well as self-insured plans that contract out to third party payers. [Plans with a “grandfathered” status–a plan in existence before March 23, 2010 that cannot make significant changes to coverage–were exempt].
A 2015 report published by the Assistant Secretary of Planning and Evaluation (ASPE) estimated that 137 million Americans received access to no-cost preventive services through private health insurance, including nearly 29 million children and 55 million women. An analysis by HHS indicated that this requirement expanded access to no-cost preventive care to 76 million Americans, including 30 million women.
The required preventive services are selected based on recommendations made by the U.S. Preventive Services Task Force (USPSTF), the Advisory Committee on Immunization Practices (ACIP), HRSA’s Bright Future’s Program, and the HRSA/IOM committee on women’s clinical preventive services. The services recommended by USPSTF, ACIP, and the Bright Future’s Program went into effect for plans beginning on or after September 23, 2010; the women’s preventive services requirement went into effect for plans beginning on or after August 1, 2012. [This brief from the Guttmacher Institute details the “contraceptive mandate,” or the coverage of no-cost contraception, by the ACA].
Preventive services receive a letter grade recommendation (A, B, C, D, or I): “A” or “B” means the service is recommended and the benefit is moderate to significant; a “C” means the committee recommends against widespread use of the service but individual patients might benefit; a “D” means the service is discouraged and that the service has moderate or high certainty of no benefit or the harm outweighs the benefit; an “I” indicates insufficient evidence to determine benefits versus harms. The committee does not consider the financial cost of preventive services when making recommendations.
While there has been controversy over some USPSTF recommendations, the impact of this requirement, both in terms of health and health care cost, is expected to grow over time.