Preventive Care Services

Without cost sharing

Preventive Services

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

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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 a precise list and codes associated with Preventive Care, refer to the Preventive Care Services Coverage Determination Guideline.

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.

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 and mammography screening including 3-D mammography 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
  • Depression screening
  • Diabetes screening
  • Hepatitis C screening
  • High blood pressure, diabetes and depression screening
  • Lung cancer screening for those age 55 to 80 using low-dose computed tomography (CT) with prior authorization
  • Screening and counseling in a primary care setting for alcohol or substance abuse, tobacco use, obesity, diet and nutrition

Women's health

  • 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 for women age 21 to 65
  • Counseling for cancer prevention strategies for women at high risk for breast cancer
  • 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
  • Breast-feeding support, supplies, and counseling, including costs for obtaining specified breast-feeding equipment from a network provider or national durable medical equipment supplier*
  • Domestic violence screening and counseling
  • FDA approved contraception methods, sterilization procedures and contraceptive counseling
  • 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

Men's health

  • Abdominal aortic aneurysm screening in men (age 65 to 75) who ever smoked
  • Human papillomavirus (HPV) vaccine for males age 9 to 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

Formal screening of children for:

  • Developmental problems and autism age 0 to 2 years
  • Counseling and fluoride varnish (age 0 to 5) to prevent dental cavities in a primary care setting

Preventive drugs at an appropriate age, gender or risk status:

The following drugs and supplements are covered without cost-share if the health plan has pharmacy coverage through UnitedHealthcare, and the drugs, even if over-the-counter, are prescribed by a health care professional and filled at a network pharmacy:

  • Aspirin for men age 45 to 79 and women age 55 to 79
  • FDA-approved female contraception methods
  • Fluoride supplements for children age 0 to 16
  • Folic acid supplements for women
  • Risk-reducing breast cancer medications for women, with prior authorization
  • Iron supplements for children age 0 to 1
  • Tobacco cessation drugs (may require prior authorization)
  • Vitamin D supplements

Religious Exemption and Eligible Organizations

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. 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 rules also contain an exemption for Eligible Organizations, which are defined as either a nonprofit organization or closely held for-profit entity with religious objections to covering contraceptive services.

The rules define a "closely held for-profit entity" as an entity that:

  • Is not a non-profit entity
  • Is not publicly traded
  • Has more than 50 percent of the value of its ownership interest owned directly or indirectly by five or fewer individuals, or has a substantially similar ownership structure, as of the date of the entity's self-certification or notice to HHS
  • Has, through its highest governing body (e.g., board of directors), adopted a resolution establishing that it objects to covering some or all contraceptives on account of the owners' sincerely held religious beliefs

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