Preventive Care Mandates

Under the Affordable Care Act, new health insurance plans with effective dates of September 23, 2010 or later must cover the following preventive services without cost-sharing for the patient (ie, no deductible, copay, or coinsurance), as long as the preventive care is received from an in-network provider.  Most of the services are detailed in the US Preventive Services Task Force (USPSTF) recommendations.

Covered Preventive Services – Adults

  • Abdominal aortic aneurysm one-time screening for men age 65 – 75 who have ever smoked
  • Alcohol misuse screening with counseling for those who are misusing alcohol
  • Aspirin as an intervention to prevent CVD (men, age 45 – 79, women age 55 – 79) unless contraindicated
  • Blood pressure screening for all adults
  • BRCA screening for women whose family history indicates an elevated risk of breast cancer
  • Breast cancer chemoprevention medication for women with an elevated risk of breast cancer – pros and cons of this therapy should be discussed with patient
  • Cervical cancer screening for sexually active women
  • Chlamydia screening for sexually active women 24 and younger, or older women who are at an increased risk
  • Cholesterol screening for men age 35 and older, and women age 45 and older.  Younger adults should also be screened if they are at an elevated risk for cardiovascular disease
  • Colorectal cancer screening for adults over 50 (this has been mandated in Colorado since July 1, 2009 and Colorado also requires health insurance carriers to cover colorectal cancer screening for all adults deemed to be at high risk, regardless of age - see Colorado HB1410 from 2008)
  • Depression screening for adults
  • Gonorrhea screening for all women with an elevated risk of contracting gonorrhea
  • Type 2 diabetes screening for adults with blood pressure greater than 135/80
  • Diet counseling for adults at who have an elevated risk for heart disease, obesity and other diet-related chronic conditions
  • HIV screening for all adults at higher risk
  • Adult Vaccines (dosage, recommended populations and ages vary, and some of these vaccines are only recommended as intermittent boosters – for example, they recommend a one-time dosage of the Tetanus, diptheria, acellular pertussis vaccine followed by a Td booster every ten years.  Other vaccines are contraindicated by things like pregnancy or a compromised immune system.)
  • Obesity screening and counseling for all adults
  • Osteoporosis screening for women over 65, or over 60 for women with an elevated risk of osteoporosis-related fractures
  • Mammogram to screen for breast cancer – every one to two years for women over 40 (Colorado requires coverage for women regardless of age if a physician recommends it based on risk assessment)
  • Sexually transmitted infection prevention counseling for adults at increased risk of contracting STIs
  • Tobacco use screening for all adults and interventions to help tobacco users quit
  • Syphilis screening for adults with risk factors

Covered Preventive Services – Pregnant women

  • Anemia screening on a routine basis for pregnant women
  • Bacteriuria urinary tract or other infection screening for pregnant women
  • Breastfeeding interventions to support and promote breastfeeding
  • Chlamydia screening for pregnant women with an elevated risk of chlamydia
  • Folic acid supplementation recommended for all women planning or capable of pregnancy
  • Hepatitis B screening for pregnant women at their first prenatal visit
  • Rh incompatibility screening for all pregnant women and follow-up testing for women who are Rh negative (unless the father is also Rh negative)
  • Tobacco use screening for pregnant women with pregnancy-tailored counseling designed to help expectant mothers quit smoking
  • Syphilis screening for all pregnant women
Additional Women’s Preventive Care
  • Well woman exams
  • Screening for gestational diabetes
  • HPV screening for women 30 and older
  • HIV screening and counseling
  • Sexually transmitted infection screening and counseling
  • Contraceptive counseling and FDA-approved contraceptives
  • Breastfeeding support, supplies and counseling
  • Domestic Violence screening and counseling

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Covered Preventive Services – Children (this chart provides age-specific guidelines)

  • Alcohol and drug use screening for adolescents
  • Autism screening for toddlers (at 18 and 24 months)
  • Behavioral assessments for children of all ages
  • Cervical dysplasia screening for sexually active adolescent females
  • Congenital hypothyroidism screening in newborns
  • Developmental screening for children at several points during infancy and early childhood
  • Dyslipidemia screening for children at higher risk of lipid disorders
  • Fluoride supplementation for children without fluoride in their water source
  • Gonorrhea prophylactic drops for newborns’ eyes
  • Hearing  and vision screening (hearing for newborns, both vision and hearing throughout childhood)
  • Height, weight, and body mass index measurements for children
  • Hematocrit or hemoglobin screening by 12 months (with supplemental iron for infants 6 – 12 months at increased risk of anemia)
  • Hemoglobinopathies or sickle cell screening for newborns
  • HIV screening and STI prevention counseling for adolescents with an elevated risk
  • Immunization vaccines for children from birth to age 18 (dosage and recommendations as far as ages and populations to be vaccinated tend to change quite a bit over time.  Be sure to check with your child’s doctor to see what the most current recommendations are.  The following links are current as of 2011)
    (specific schedule for children age 0 – 6 years)
    (specific schedule for children age 7 – 18 years)
    (catch-up schedule for children who are more than one month behind on vaccinations)
  • Lead screening for children at risk of exposure
  • Medical history for all children at every check up
  • Obesity screening and counseling
  • Oral health screening in early childhood
  • Phenylketonuria screening for newborns
  • Tuberculin testing for children at higher risk of tuberculosis or a possible exposure to tuburculosis

Please note that this list of preventive services and coverage levels is for informational purposes only, to give you a rough idea of how the PPACA has transformed preventive care.  Always consult your policy booklet to determine the specific coverage provided.  If your policy says something other than what’s listed here, your policy should be regarded as the correct information.

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