Preventive Health Services Under the Affordable Care Act:

Translating Law Into Coverage

Naomi Seiler, JDAssociate Research Professor

George Washington University School of Public Health and Health Services, Department of Health Policy

Vitality Institute Health Promotion ForumFebruary 20, 2014

Coverage of Preventive Services

Section 2713 of the Affordable Care Act (ACA) includes:

(1) Evidence-based items or services rated A or B by the U.S. Preventive Services Task Force

(2) ACIP-recommended immunizations

(3) Preventive care for infants, children, and adolescents recommended by HRSA,

(4) Additional preventive care and screenings for women recommended by HRSA.

Covered Preventive Services for All Adults (adapted from www.healthcare.gov)

•Abdominal Aortic Aneurysm one-time screening for men of specified ages who have ever smoked•Alcohol Misuse screening and counseling•Aspirin use to prevent cardiovascular disease for men and women of certain ages•Blood Pressure screening for all adults•Cholesterol screening for adults of certain ages or at higher risk•Colorectal Cancer screening for adults over 50•Depression screening for adults•Diabetes (Type 2) screening for adults with high blood pressure•Diet counseling for adults at higher risk for chronic disease•HIV screening for everyone ages 15 to 65, and other ages at increased risk•Immunization vaccines for adults--doses, recommended ages, and recommended populations vary•Obesity screening and counseling for all adults•Sexually Transmitted Infection (STI) prevention counseling for adults at higher risk•Syphilis screening for all adults at higher risk•Tobacco Use screening for all adults and cessation interventions for tobacco users

Covered Preventive Services for Women(adapted from www.healthcare.gov)

•Anemia screening on a routine basis for pregnant women•Breast Cancer Genetic Test Counseling (BRCA) for women at higher risk for breast cancer•Breast Cancer Mammography screenings every 1 to 2 years for women over 40•Breast Cancer Chemoprevention counseling for women at higher risk•Breastfeeding comprehensive support and counseling and access to breastfeeding supplies•Cervical Cancer screening for sexually active women•Chlamydia Infection screening for younger women and other women at higher risk•Contraception: Food and Drug Administration-approved contraceptive methods, sterilization, counseling•Domestic and interpersonal violence screening and counseling for all women•Folic Acid supplements for women who may become pregnant•Gestational diabetes screening for women 24 to 28 weeks pregnant and those at high risk •Gonorrhea screening for all women at higher risk•Hepatitis B screening for pregnant women at their first prenatal visit•HIV screening and counseling for sexually active women•Human Papillomavirus (HPV) DNA Test every 3 years for women 30 or olderwith normal cytology•Osteoporosis screening for women over age 60 depending on risk factors•Rh Incompatibility screening for all pregnant women and follow-up testing for women at higher risk•Sexually Transmitted Infections counseling for sexually active women•Syphilis screening for all pregnant women or other women at increased risk•Tobacco Use screening and interventions for all women, expanded counseling for pregnant women•Urinary tract or other infection screening for pregnant women•Well-woman visits to get recommended services for women under 65

Covered Preventive Services for Children(adapted from www.healthcare.gov)

ACA: Many people will now have access to these preventive services without cost-sharing…

…but coverage varies significantly by insurance type.

Coverage of Section 2713 Preventive Services: Private Insurers

• All non-grandfathered private plans must cover without cost-sharing

• Applies both inside and outside Exchanges

Coverage of Section 2713 Preventive Services: Private Insurers (cont.)

Cost-Sharing for Preventive Service vs. Associated Office Visit:

•If preventive service billed separately from visit, may impose cost-sharing for the visit.

•If service not billed separately, and primary purpose is delivery of that service, may not impose cost-sharing.

•If service not billed separately, and primary purpose is not delivery of that service, the plan may not impose cost-sharing for the preventive service but may impose cost-sharing for the visit.

•Plan may impose cost-sharing for any treatment that “results” from a Section 2713 preventive service.

Coverage of Section 2713 Preventive Services: Private Insurers (cont.)

Network v. Out-of-Network Providers: 

If a plan uses a network, not required to cover preventive services out-of-network.

If does cover preventive services out-of-network, may impose cost-sharing.

But if no in-network provider available to perform a preventive service, the plan must cover the service when offered by an out-of-network provider, and can’t impose cost-sharing.

Coverage of Section 2713 Preventive Services: Private Insurers (cont.)

“Frequency, method, treatment, or setting”:

•If the USPSTF, ACIP, or HRSA recommendation or guideline does not specify the “frequency, method, treatment, or setting” for a preventive service, a plan may use “reasonable medical management techniques” to apply coverage limitations.

•According to the preamble to the interim final rules, a plan may “rely on established techniques and the relevant evidence base” to establish such limitations.

Coverage of Section 2713 Preventive Services: Medicare

• ACA does not require Medicare to cover Section 2713 preventive services.

• If Medicare does cover any of the USPSTF- or ACIP-recommended services, ACA requires that it do so without any cost-sharing (note that HRSA recommendations are not included under these provisions).

Coverage of Section 2713 Preventive Services: Medicare (cont.)

• However, Medicare does not have to follow USPSTF’s recommendations on types of provider or setting.

• Some Medicare preventive services are only covered when offered by a primary care provider in a primary care setting.

Coverage of Section 2713 Preventive Services: “Traditional” Medicaid

• ACA incentivizes states to provide additional preventive services to Medicaid beneficiaries by providing an increase of 1% in the Federal medical assistance percentage (FMAP) if a state does provide coverage for all USPSTF- or ACIP-recommended services and immunizations.

Coverage of Section 2713 Preventive Services: “Traditional” Medicaid (cont.)

• It appears that only a handful of states have elected to cover all USPSTF and ACIP services and receive the 1% FMAP boost.

• Lack of clarity on what services states are covering in general.

• States now have the option of reimbursing other state-certified providers for preventive services (contrast to Medicare).

Coverage of Section 2713 Preventive Services: “Expansion” Medicaid

• Under ACA and subsequent rules, all Medicaid “expansion” plans must cover all preventive services included under Section 2713, without any cost sharing.

So Where Does This Leave Us?

Efforts to Promote Awareness

• How do we communicate complex coverage changes to patients?

• How do we communicate complex coverage changes to providers?

Policy Change

• If assume no Congressional legislation is imminent…

• Medicaid coverage policy decisions are now largely at the state level

• How to convince states to cover all USPSTF and ACIP services?

• Is there a way to broaden scope of Medicare coverage?

Enforcement

• Like most of ACA, enforcement under private plans is largely in the hands of state insurance commissioners.

• Will this suffice with regard to coverage of preventive services?

Research

• How are issuers interpreting the law and guidance?

• Are providers getting appropriate reimbursement?

• How does coverage intersect with bundled payments?

• Is expanded coverage increasing uptake?

• Is increased uptake improving health?

Thank you.

Naomi Seiler

nseiler@gwu.edu