One promising aspect of the Patient Protection and Affordable
Care Act1 (ACA) is the opportunity for increased access
to preventive health services. Since 2010, most health plans have
been required to cover a range of services, such as annual wellness
visits and cancer screenings, without cost-sharing by plan members.
For consumers, particularly those with limited incomes, this
mandate reduces financial obstacles to better health.
Unfortunately, implementation by health plans has been uneven,
leaving members with uncovered charges. More oversight and broader
consumer engagement is needed for the preventive services mandate
to have its intended broad effect.
Even with health insurance, many consumers face unaffordable
health care costs. From $25 copays for physician visits to 20
percent coinsurance for medical procedures, having health insurance
does not insulate people from medical bills. As a result, many
low-income consumers have avoided necessary care. Ideally, ready
access to preventive services leads to better health and reduced
medical costs over time.
Through the ACA, Congress sought to eliminate the financial
disincentives to obtaining preventive health care. The ACA mandates
that group health plans and health insurance issuers cover a range
of preventive health services without cost-sharing. This mandate
applies to the majority of health plans, including
employer-sponsored plans, student health insurance, and private
non-group insurance.2 Most privately insured residents
of Massachusetts have health plans subject to the preventive
services mandate. The preventive services mandate represents one of
the major benefits available to Massachusetts residents under
Neither the text of the ACA nor the law's implementing
regulations specifies the preventive services that health plans
must cover without cost-sharing. Instead, the law and regulations
refer to guidelines and recommendations issued by the Centers for
Disease Control and Prevention, the Health Resources Services
Administration and the United States Preventive Services Task
Force. By incorporating these guidelines and recommendations, the
ACA allows for flexibility in determining services subject to the
mandate over time. This flexibility will be important as new
standards and technologies develop in preventive medicine.
For adults, preventive services that must be covered without
cost-sharing include screening for colorectal, breast and cervical
cancers, blood tests for cholesterol and sexually transmitted
infections, and counseling for certain conditions.4
Preventive services that must be provided for children at no cost
include regular immunizations, certain blood tests, and vision and
hearing exams.5 Additional services that must be covered
for women include an annual physical, the full range of
FDA-approved contraceptive methods, and lactation equipment and
Consistent with the law, implementation of the preventive services
mandate began shortly after the ACA's passage, with plan years
beginning on or after Sept. 23, 2010.7 The mandate
relating to coverage of preventive services for women was delayed
until Aug. 1, 2012.8
Despite the relatively swift implementation of the mandate,
putting the preventive services benefit fully into effect has been
fraught with difficulty. This is due in part to the lack of
specificity in the statute and regulations. Health care providers
and health plans communicate through a complex system of medical
billing codes. The recommendations issued by the Preventive
Services Task Force and other responsible agencies list services
generally, without diagnosis or procedure codes. This disconnect
between the recommendations and the way that services are
identified and authorized by health plans has led to differential
treatment of consumers depending on the plan.
Further, the mandate allows for the use of "reasonable medical
management" by health plans. This means that health plans may
determine coverage limitations and cost-saving techniques where the
guidelines do not specify the frequency, method, or setting for a
service. This medical management "loophole" has also resulted in
wide variation among health plans.
The ACA's promise of cost-free contraception demonstrates the
inconsistent application of the preventive services benefit. Upon
the benefit's initial implementation, many health plans offered
only oral contraceptives at no cost, while imposing
cost-sharing for other methods. Further, many plans covered only
generic contraceptives at no cost. Due to this confusion, the
Employee Benefits Security Administration (EBSA) issued guidance in
February 2013.9 EBSA clarified that a health plan must
cover the full range of FDA-approved contraceptive
methods. EBSA further clarified that health plans may limit
cost-free coverage to generic alternatives but only if
medically appropriate for the patient.
EBSA has issued extensive guidance on many aspects of the
preventive services benefit. This guidance has offered greater
clarity to health plan members seeking preventive health services.
Nonetheless, health plans may still determine coverage limitations
where federal law does not specify the frequency or method of
treatment. Thus, with respect to cancer prevention, patients face
confusion about coverage for colorectal, breast and cervical cancer
screenings. For example, health plans differ as to whether future
colorectal cancer screening must be cost-share free for a patient
that had polyps removed during a prior colonoscopy. Also unresolved
is the question of whether more frequent screenings due to higher
risk of cancer (such as indicated by colon polyps) must be covered
Impact on Prevention
The interim final rule, released in July 2010, underscores three
main factors that contribute to underutilization of preventive
health services and the need for federal action: (1) health
insurers have no financial incentive to cover preventive services
as the cost-saving benefits are long-term and lost entirely when
members switch health plans; (2) individuals do not see an
immediate benefit from preventive services and thus do not obtain
them; and (3) the benefits of preventive care are most evident
population-wide, requiring centralized action to provide incentives
on a broad scale. The ACA seeks to provide a clear incentive to
health plan members to obtain preventive care. However, the
inconsistent implementation of the mandate has eroded this consumer
Further federal guidance and enhanced consumer engagement are
needed for the preventive services mandate to have its intended
broad effect. To increase utilization of preventive health care,
thereby improving population health and reducing long-term health
system costs, health plans and insurers must implement the mandate
more consistently. Federal guidance since 2010 has not led to
uniform implementation across health plans. This lack of uniformity
has undermined consumer confidence in the ACA's preventive services
benefit, likely hindering the intended impact of this important
provision. And yet, consumers can assert their own rights in
enforcing the preventive services mandate. When faced with
unanticipated costs for preventive services, members should
challenge health plan determinations. The health plan appeal
process plays an important role in protecting consumers' rights and
can lead to meaningful change within health plan policies.
It is too early to tell whether the ACA's preventive services
mandate will meet its goal of improving overall health and reducing
health system costs. The implementation process has been uneven
and, in many ways, marked by confusion for plans and consumers
alike. More federal guidance and oversight and broader consumer
engagement are needed for the preventive services mandate to have
its full beneficial effect.
1Patient Protection and Affordable Care Act (ACA),
Pub. L. 111-148, § 2713(a), 124 Stat. 119 (2010).
2Only "grandfathered" plans are exempt from the
preventive services mandate, To qualify as "grandfathered" a plan
had to be in effect on March 23, 2010 and have made no significant
changes to coverage since that time.
3Chapter 58 of the Acts of 2006 substantially reformed
Massachusetts' health insurance system and served in part as the
template for federal reforms under the ACA.
4United States Preventive Services Task Force's A and B
Recommendations,available at www.uspreventiveservicestaskforce.org/uspstf/uspsabrecs.htm.
5American Academy of Pediatrics' Recommendations for
Pediatric Preventive Care, available at www.aap.org/en-us/professional-resources/practice-support/Periodicity/Periodicity%20Schedule_FINAL.pdf.
6Health Resources Services Administration's Women's
Preventive Services Guidelines, available at www.hrsa.gov/womensguidelines
775 Fed. Reg. at 41726 (July 19, 2010).
876 Fed. Reg. at 46621 (Aug. 1, 2011).
9United States Department of Labor. Employee Benefits
Security Administration's Frequently Asked Questions (FAQ) about
Affordable Care Act Implementation Part XII, released Feb. 20,
2013, available at www.dol.gov/ebsa/faqs/faq-aca12.html.
10For a detailed analysis of health plans' implementation of
the colorectal cancer screening benefit, see Coverage of
Colonoscopies under the Affordable Care Act's Prevention Benefit,
Karen Pollitz, MPP, Kaiser Family Foundation, et al. (September
Nancy K. Ryan is a staff attorney at Health Law Advocates, a
public interest law firm offering free legal assistance to
low-income consumers. She represents clients challenging health
plan denials of coverage under HLA's Commercial Health Insurance