4 Categories of Preventive Care Services Covered Under the ACA

There are four types of services that private payers and employers are required to cover under the Affordable Care Act (ACA) preventive care services provision, which include screenings and immunizations, according to a Kaiser Family Foundation (KFF) fact sheet.

Under the ACA, payers must cover these services without cost-sharing:

• Screenings and counseling
• Routine immunizations
• Preventive services for women
• Preventive services for children and youth

“These requirements apply to all private plans—fully insured and self-insured plans in the individual, small group, and large group markets, except those that maintain ‘grandfathered’ status,” the fact sheet explained.

“Individual and small group plans in the health insurance marketplaces are also required to cover an essential health benefit (EHB) package—that includes the full range of preventive requirements described in this fact sheet.”

Payers must cover the screening and counseling requirements based on USPSTF recommendations. Screening and counseling recommendations that receive an A or B rating must be fully covered.

At the time of this article’s publication, USPTF recommended screenings for conditions such as sexually transmitted infections, depression, obesity, diabetes, prenatal tests, breast cancer, and heart disease. The list included some of the most expensive chronic diseases in the US.

USPSTF recommended counseling for drug and tobacco use and eating habits. These recommendations and those about screenings may include age or gender-related factors that affect the rating level.

For example, USPSTF encourages screening children eight or older for anxiety. However, the task force has not acquired enough data to make a recommendation for children younger than eight.

Payers also have to cover routine immunizations per the recommendations of the Advisory Committee on Immunization Practices (ACIP), a federal immunization committee. ACIP recommendations are finalized when adopted by the director of the Centers for Disease Control and Prevention (CDC).

As of May 2023, the immunization list covered conditions including but not limited to HPV, hepatitis A and B, rubella, influenza, and tetanus.

The COVID-19 vaccine is also on the list but operates under a different procedure than most immunization recommendations. Due to a Congressional waiver, the coronavirus vaccine and booster shot coverage requirement goes into effect 15 days after the CDC director adopts the recommendation.

The ACA rules around covering preventive care services for women are based on USPSTF and ACIP recommendations. But they also consider Health Resources and Services Administration (HRSA) guidelines, which draw from the Women’s Preventive Services Initiative (WPSI) standards.

To comply with the requirements of preventive care services for women, payers must fully cover well-woman visits, breastfeeding support, and screening and counseling related to intimate partner violence and other conditions and circumstances. Contraceptives approved, granted, or cleared by the Food and Drug Administration (FDA) are also covered.

Overall, adults can access free services for cancer, chronic diseases, health promotion, reproductive health, and pregnancy.

ACA preventive care coverage also encompasses services for children. These requirements are based on HRSA’s Bright Futures Project. They include well-child visits, immunizations, screenings, behavioral and developmental assessments, and more.

Overall, the law requires payers to fully cover preventive care services for children and youths related to infectious and chronic diseases, child development, sexual health for adolescents, health promotion, and immunizations.

Full coverage for these services may be less ubiquitous if a legal challenge to this provision succeeds.

In March 2023, a district court judge ruled against the Affordable Care Act’s preventive care services provision. Specifically, the judge determined that it violated the religious freedoms of employers who did not want to cover preventive care services such as PrEP and contraceptives due to their personal beliefs.

Two months later, the US Court of Appeals for the Fifth Circuit ruled that employers and health insurers must comply with the ACA’s preventive services provisions while litigation continues.