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Preventive Care Services

Timeline of Provisions

Preventive Care Services

Without cost sharing

Video: Preventive Services

The Affordable Care Act contains a provision to make certain preventive services available without co-pays, co-insurance or deductibles. View video

Summary

A non-grandfathered group health plan and a health insurance issuer offering group or individual health insurance coverage must provide coverage for preventive care without any cost-sharing (copayments, coinsurance or deductible) requirements as long as services are rendered by physicians and other health care professionals who participate in the plan's network.

This preventive services provision applies to both fully insured and self-funded plans. While grandfathered plans are not required to implement these changes, some grandfathered plans have chosen to offer preventive care services at no cost-share.

Additional preventive care services for women will be covered as part of the health reform law effective on the health plan's first renewal date on or after Aug. 1, 2012. For information on the expanded list of women's preventive coverage, please read UnitedHealthcare's Approach to Women's Preventive Care Services (PDF).

In addition to services mandated by the health reform law, UnitedHealthcare also applies preventive care services benefits to certain services above and beyond the health reform law's requirements including colorectal cancer screening using CT colonography, prostate-specific antigen (PSA) screening for prostate cancer, and mammography screening for all adult women. These services are marked below with an asterisk.*

All members

  • Yearly preventive care visits for adults (male* and female)
  • All standard immunizations recommended by the American Committee on Immunization Practices

All members at an appropriate age or risk status

  • Colorectal cancer screening (including CT colonography*, fecal occult blood testing, screening sigmoidoscopy, and screening colonoscopy)
  • Cholesterol and lipid disorders
  • Certain sexually transmitted diseases screening including HIV
  • High blood pressure, diabetes and depression screening
  • Screening and counseling in a primary care setting for alcohol or substance abuse, tobacco use, obesity, diet and nutrition

Women's health

The following guidelines for women were effective for plan years beginning on or after Sept. 23, 2010:

  • Mammography screening (film and digital) for all adult women*
  • Genetic screening and evaluation for the BRCA breast cancer gene
  • Cervical cancer screening including Pap smears
  • Sexually transmitted diseases screening including gonorrhea, Chlamydia, syphilis and HIV
  • Iron-deficiency anemia, bacteriuria, hepatitis B virus and Rh incompatibility screening in pregnant women
  • Breast-feeding counseling and promotion
  • Osteoporosis screening (age 60 and older)*
  • Counseling women at high risk of breast cancer for chemoprevention

Expanded women's preventive care services on or after Aug. 1, 2012

New coverage guidelines under the Patient Protection and Affordable Care Act (PPACA) require health plans to cover an expanded list of women's preventive care services with no cost-share (copayment, coinsurance or deductible) as long as services are received in the health plan's network. Coverage for the following expanded women's preventive care services becomes effective the first plan year beginning on or after Aug. 1, 2012:

Men's health

  • Prostate cancer screening for men (age 40 and older)*
  • Abdominal aortic aneurysm screening in men (age 65-75) who ever smoked
  • Human papillomavirus (HPV) vaccine for males age 9-26

Children

  • Newborn screening for hearing, thyroid disease, phenylketonuria and sickle cell anemia and standard metabolic screening panel for inherited enzyme deficiency diseases
  • Counseling for fluoride use
  • Major depressive disorders screening
  • Vision screening
  • Developmental/autism screening
  • Lead and tuberculosis screening
  • Obesity counseling

The Department of Health and Human Services has defined the preventive services to be covered with no cost-share as those services described in the U.S. Preventive Services Task Force A and B recommendations, the Advisory Committee on Immunization Practices (ACIP) of the Centers for Disease Control and Prevention (CDC), and certain guidelines for infants, children, adolescents and women supported by the Health Resources and Services Administration (HRSA) Guidelines including the American Academy of Pediatrics Bright Futures periodicity guidelines.

For More Information

Employers, Brokers and Consultants

Members/Consumers

Physicians/Health Care Professionals/Others

Frequently Asked Questions

Breast-feeding Supplies/Breast Pumps

When can a woman order her breast-feeding equipment?

Members can order their breast pumps within 30 days of their baby?s estimated delivery date. Personal use double-electrical pumps are covered without cost-share for women in conjunction with childbirth.

How does a member receive a breast pump without cost-share?

A member must contact a network doctor or one of our national durable medical equipment (DME) suppliers. The supplier will issue the breast pump directly to the member. The doctor or DME supplier will bill UnitedHealthcare directly for reimbursement. Members may call the number of the back of their ID card for DME supplier information.

May members purchase a breast pump at a retail store and turn in the receipt for reimbursement?

No. Members may only obtain a breast pump through a network doctor or DME supplier.

Is prior authorization required for a breast pump?

Currently, prior authorization is not needed for breast pumps. Providers will need to bill for breast pumps consistent with our Preventive Care Services Coverage Determination Guideline (PDF), or they can direct women to one of the national DME suppliers to get their breast pump. Providers will verify that a woman is eligible to receive a breast pump as a preventive service.

Colonoscopy

How does UnitedHealthcare cover colon cancer screenings?

Under the health reform law, preventive colorectal cancer screenings are covered without cost-share. UnitedHealthcare covers colonoscopy, sigmoidoscopy and fecal occult blood testing without cost-sharing for all members at an age-appropriate age and/or risk status. UnitedHealthcare also covers CT colonography as a preventive screening test for colorectal cancer for commercial members. All services for a preventive colonoscopy (e.g. associated facility, anesthesia, pathologist, and doctor fees) are processed under the preventive care services benefit and covered without cost-share.

Contraception Coverage

What if a doctor doesn't maintain an inventory of IUDs in his or her office and asks the member to purchase an IUD at a pharmacy?

IUDs can be expensive for doctors to purchase and stock in their offices. Doctors who do not stock IUDs can obtain the Mirena® brand levonorgestrel-releasing intrauterine system "on demand" from CVS Caremark Specialty Pharmacy. Contact CVS Caremark at 1-800-237-2767 or Fax 1-800-323-2445.

Please note that we cannot reimburse members who purchase IUDs at a pharmacy, even if that pharmacy is a network pharmacy because IUDs are covered under the medical benefit, not the pharmacy benefit.

Are all female contraceptives covered at 100 percent under the expanded women's preventive care services benefit?

No. While all FDA-approved methods are covered without cost-share under the health reform law, that does not mean all contraceptives. The methods covered by the pharmacy benefit are hormonal (e.g. birth control pills), barrier (i.e. diaphragms) and emergency contraceptives (i.e. "morning after" pills) and certain over-the-counter contraceptives (e.g, female condoms). UnitedHealthcare provides Tier 1 contraceptives for each method without cost-share. Review your Tier 1 prescription drug list for specific types and brands that are covered.

Are contraceptives that are provided through a doctor's office, like Depo-Provera® covered without cost-share?

Contraceptives administered by a network doctor in a medical setting, such as sterilization and services to place/remove/inject contraceptive methods like Depo-Provera or IUDs, will be covered at 100 percent under the medical benefit of non-grandfathered plans and other plans that adopt the health care reform preventive care coverage. Some contraceptives, like birth control pills, are covered under the pharmacy benefit at 100 percent when filled at a network pharmacy. Because the effective date of coverage of preventive services under the medical benefit and the pharmacy benefit may differ, it is possible that some members may have coverage at 100% for contraception under the pharmacy benefit before they have contraceptive or sterilization coverage at 100% under the medical benefit.

Does the health reform law require covering abortion or abortion pills?

No. The health reform law does not provide for coverage of abortion/abortifacient drugs/abortion pills as a preventive service. The health reform law requires covering emergency contraceptive methods as prescribed. This includes certain "morning after" pills, such as Plan B One-Step® and ella®, which are FDA-approved emergency contraception.

Mammograms

How does UnitedHealthcare cover mammograms?

The health reform law requires coverage of screening mammography for women age 40 and older every 1-2 years without cost-share. UnitedHealthcare believes mammography is a critical tool for early cancer detection and does not impose an age or frequency limit on breast cancer screenings. We cover screening mammography for all adult women.

Out-of-Network Coverage

Are preventive services received outside the network covered at 100 percent?

The health reform law does not require plans and issuers to cover preventive care services, including expanded women's preventive services, received from out-of-network providers. If a plan covers out-of-network preventive services, the plan or issuer may impose cost-sharing requirements, unless an applicable state law otherwise requires first-dollar coverage. If a plan does not cover out-of-network preventive services, then out-of-network preventive services generally will not be covered. However, if a plan does not cover out-of-network preventive services, but does have out-of-network medical benefits, then UnitedHealthcare will cover out-of-network routine prenatal office visits under the plan's out-of-network medical benefits. Any cost-sharing under the out-of-network medical benefit would apply to the prenatal office visits.

Flu Vaccines

Are flu shots covered at 100 percent?

Yes, the health reform law mandates that certain immunizations, including flu shots, are paid as preventive services without cost sharing when provided in a network doctor office for non-grandfathered plans. In some benefit designs, flu shots may be paid as preventive services when offered in other settings such as pharmacies. When flu shots in pharmacies are covered as a preventive service, they are paid as a medical benefit, rather than a pharmacy benefit.

Well-Woman Visits and Prenatal Care

Are postnatal visits covered as preventive under well-woman visits?

Well-woman visits, as defined by the health reform law, include visits to obtain the recommended preventive care services, including preconception counseling and prenatal care. Postnatal care to treat the mother after the baby is born is not covered as a preventive benefit, and cost-sharing may apply.

Are ultrasounds covered without cost-sharing under the women's preventive benefit?

While radiology services like ultrasounds may be part of prenatal care, they are not required under the health reform law to be covered at 100 percent. A copayment, coinsurance or deductible may apply for these services.

Is a pregnancy test considered a prenatal preventive service covered without cost-share?

No, a pregnancy test is not a preventive service, and cost-sharing may apply.

Prenatal, delivery and postnatal are often included in a global maternity fee. How will UnitedHealthcare only pay just the prenatal care at 100%?

Often maternity charges are billed together as a "global" maternity fee under a global obstetrical code. Under the health reform law, the prenatal portion of the visit must be covered as a preventive benefit to be paid without cost-share to the member, and the delivery and postpartum portion of the visit may be paid as a medical benefit with cost-share to the member.

Based on certain payment methodologies of the Centers for Medicare & Medicaid Services (CMS), UnitedHealthcare determined that 44 percent of the global OB code should be considered prenatal care and paid as preventive with no member cost-sharing, and 56 percent will be considered delivery and postpartum care which may include member cost-sharing. The appropriate fee will calculate based on this percentage. The process will be seamless to members, doctors and health care professionals.

Religious Employer Exemption and Eligible Organization

What if an organization does not want to cover contraceptives?

Under the final rules, certain religious employers, and group health insurance coverage in connection with such plans, are exempt from the requirement to cover contraceptive services. A religious employer is organized and operated as a non-profit organization and referred to under code section 6033(a)(3)(A)(i) or (iii), which refers to churches, other houses of worship, their integrated auxiliaries and conventions or association of churches, as well as the exclusively religious activities of any religious order. This new definition more broadly defines a religious employer. Those who previously did not qualify may now meet these requirements. Organizations that qualify for the religious employer exemption do not provide contraceptives to its employees and its employees will not be provided contraceptive coverage.

The final rules also created a new designation: "eligible organization." An eligible organization is defined as a nonprofit religious organization with religious objections to covering contraceptive services. Organizations may self-certify as an eligible organization for plan years beginning on or after Jan. 1, 2014. This replaces the temporary enforcement safe harbor (TESH), which can be used for plan years that begin on or before 12/31/13. See more on religious exemptions to contraceptive coverage.