The Affordable Care Act contains a provision to make certain preventive services available without co-pays, co-insurance or deductibles. View video
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.*
Yearly preventive care visits for adults (male* and female)
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
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:
Gestational diabetes screening for all pregnant women*
HIV counseling and screening for all sexually active women
Human papillomavirus DNA testing for all women 30 years and older
Sexually transmitted infection counseling for all sexually active women annually
Well-woman visits including preconception counseling and routine, low-risk prenatal care
It is important to note that for renewing fully insured plans, the effective dates for medical coverage and pharmacy coverage for expanded women's preventive care services may be different. Medical coverage begins on the fully insured plan's first renewal date on or after Aug. 1, 2012, and pharmacy coverage begins on Aug. 1, 2012, regardless of the plan's renewal date as long as the group has oral contraceptive coverage today. For all other new or renewing plans, pharmacy and medical coverage becomes effective as of the first plan year, or the first health plan renewal date, on or after Aug. 1, 2012.
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
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
Lead and tuberculosis screening
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.
Communication Resource Center Find tools to promote preventive care among employees. The resource center includes an employer toolkit, posters, brochures, a presentation, emails and more.
UHC Preventive Care A consumer website that offers preventive care guidelines by age and gender plus health tips, videos and education materials on preventive care. Employers can share with employees, and embed the link into their wellness communications.
CDG Summary: A quick reference guide that summarizes the new preventive care services codes
Frequently Asked Questions
Breast-feeding Supplies/Breast Pumps
If the health reform law requires health plans to cover renting breast pumps at no cost-share why is UnitedHealthcare also covering the purchase of breast pumps without cost-share?
In addition to covering the rental of hospital-grade breast pumps, UnitedHealthcare also covers the purchase of a portable double-electric breast pump without cost-share. Only hospital-grade breast pumps are intended to be rented since they are designed for multiple users. We believe many members will prefer to purchase a more portable and convenient electric breast pump rather than rent hospital-grade equipment.
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 ship 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.
Is there a time limit that a woman must purchase or rent breast-feeding equipment following the birth of her baby to qualify without cost-share?
Effective April 1, 2013, personal use double-electrical pumps are covered for women who are lactating and request a breast pump within one year (365 days) following delivery. Hospital-grade breast pumps and the personal use attachment kit are covered for members who meet the following criteria:
1. The woman is a lactating mother
2. The breast pump is obtained within the first two months (60 days) following delivery
3. The baby has one or more of the following criteria:
Congenital malformations or genetic abnormalities that impact feeding (e.g. cleft lip and palate, Down Syndrome)
After 10 months of renting, hospital-grade pumps automatically convert to a purchase.
Remember these changes are part of the expanded list of women's preventive care services that go into effect for non-grandfathered plans on the health plan's first renewal date on or after Aug. 1, 2012.
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.
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.
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.
When are contraceptives available without cost-sharing?
For renewing fully insured plans that cover preventive services at 100%, the effective dates for medical coverage and pharmacy coverage may be different. Medical coverage for women's preventive care services begins on the plan's first renewal date on or after Aug. 1, 2012, and pharmacy coverage began on Aug. 1, 2012, regardless of the plan's renewal date as long as the group had pharmacy benefit contraceptive coverage prior to Aug. 1, 2012. For all other new or renewing plans, pharmacy and medical coverage becomes effective as of the first plan year, or the plan's first renewal date, on or after Aug. 1, 2012.
Members received pharmacy benefit contraceptive coverage Aug. 1, 2012, instead of waiting for the plan's renewal date if the plan renews after Aug. 1, 2012. Because this coverage is required for all plans that are not grandfathered or religiously exempt (including temporary safe harbor), we provided this pharmacy benefit contraceptive coverage early (if the plan renews after Aug. 1, 2012).
Are all 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). 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.
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.
Are preventive services received outside the network covered at 100 percent?
The health reform law does not require that preventive care services received from out-of-network health care professionals be covered at 100 percent. If a plan does cover preventive services out of the network, a copayment, coinsurance and deductibles may apply (unless a state law otherwise requires first-dollar coverage). If a plan does not cover out-of-network preventive services, then preventive services received by out-of-network health care providers will typically not be covered.
Prescriptions and Medications
Are prescriptions or any medications covered without cost-sharing?
The health reform law provides guidance to doctors around counseling and use of certain medications (e.g., aspirin to prevent cardiovascular disease, folic acid for pregnant women, and iron and fluoride supplements for children), but the medications are not covered without cost-sharing. We do not cover over-the-counter drugs or prescription strengths of any of these drugs without cost-share.
Prescriptions medications will be covered according to the patient's prescription drug plan.
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 Temporary Enforcement Safe Harbor
What if an organization does not want to cover contraceptives?
The health reform law allows organizations a religious exemption or a temporary enforcement safe harbor for those who qualify. Qualified organizations may exclude contraceptive coverage from their health plans. The organizations requesting the exemption are solely responsible for their compliance with federal and state law regarding exemptions from contraceptive coverage requirements. The religious employer exemption and the temporary enforcement safe harbor are not available to fully insured plans in some states.