The Affordable Care Act (ACA) requires non-grandfathered group health plans and insurers to cover certain preventive services without cost sharing. This means that plans must cover specific preventive services at 100% – no deductibles, copays, or coinsurance – when delivered by an in-network provider.
The goal of this requirement is to encourage individuals to receive preventive care – such as screenings, immunizations, and counseling – without financial barriers. The idea is that when covered individuals engage in ongoing preventive care with their physicians, potential illnesses and health concerns can be identified and addressed early, making treatment more effective and less costly in the long run.
Sources of Preventive Service Requirements
Plans must cover preventive services recommended by the following bodies:
- U.S. Preventive Services Task Force (USPSTF) – Evidence-based recommendations rated “A” or “B.”
- Advisory Committee on Immunization Practices (ACIP) – Routine immunizations recommended for adults and children.
- Health Resources and Services Administration (HRSA) –
- Comprehensive guidelines for infants, children, and adolescents (Bright Futures).
- Women’s Preventive Services Guidelines (e.g., contraception, breast cancer screenings, well-woman visits).
Plans are required to update their coverage of preventive services within one plan year after a new recommendation or guideline is issued.
Key Points for Employers and Plans
- No Cost Sharing: Preventive services must be covered in full when obtained from in-network providers. Out-of-network preventive care may be subject to regular cost-sharing.
- Applies to Non-Grandfathered Plans: Grandfathered plans are not required to comply, though many do voluntarily.
- Essential Health Benefits: Preventive services fall under the broader category of Essential Health Benefits (EHBs) for fully insured non-grandfathered plans in the small group market.
- Coverage Updates: Employers with self-funded and level-funded plans and insurance carriers should monitor updates from USPSTF, ACIP, and HRSA to ensure timely compliance each year.