Health and Safety

Preventive Services Covered Under the Affordable Care Act

Febraury 22, 2016
David Frank, MD, FACP, MagnaCare Senior Medical Director

MagnaCare maintains a Preventive Services Policy for use by our self-insured plans. This policy is available to our clients for reference on their client web portal. The policy includes an up-to-date detailed listing of the necessary preventive services that are required by the Affordable Care Act (ACA).

Preventive Services Task Force Grading System

In 2010, the ACA created a link between the US Preventive Services Task Force (USPSTF) recommendations and various coverage requirements. The ACA specifies that commercial and individual or family plans must , at a minimum, provide coverage and not impose cost sharing for any evidence-based preventive services that receive a grade of A or B from the USPSTF (see table below  on the grading system) . The required offering of these preventive screening tests applies to many self-insured plans, but not necessarily all, depending on their grandfathered status.    

Grade A

Recommended

There is high certainty that the net benefit is substantial.

Grade B

Recommended

There is high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.

Grade C

No recommendation

Clinicians may provide the service to selected patients depending on individual circumstances. However, for most individuals without signs or symptoms there is likely to be only a small benefit.

Grade D

Recommended against

The Task Force recommends against this service. There is moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.

No Grade

Insufficient evidence

The current evidence is insufficient to assess the balance of benefits and harms.

At present the required preventive services per the ACA, include 15 covered preventive services for adults, 22 covered preventive services for women, including pregnant women and 26 covered preventive services for children. However, it should be noted that Plans are not prohibited from providing full or partial coverage for preventive services graded other than A or B, such that Payers currently have the latitude to cover such services in their benefit designs. Additionally, lawmakers also have the power to require coverage of non-A and non-B graded services (for example, regulation on screening mammography coverage).

Meeting Preventive Screenings Recommendations

As new and/or revised recommendations for coverage of preventive screenings are identified by the US Preventive Services Task Force (USPSTF) and others (such as  the Advisory Committee on Immunization, Bright Futures pediatrics recommendations, and Health Resources and Service Administration women’s preventive services guidelines ), Magnacare’s medical department reviews these recommendations and necessary adjustments are made to our Preventive Services Policy.  Any changes that are made to this policy will comply with the ACA. Examples of recent changes to the required preventive services include colorectal cancer screening intervals, prostate cancer screening, women’s contraceptive methods, breast cancer genetic counseling and the addition of various screening tests for transgendered individuals.

Inside Healthcare with MagnaCare President Michael Jordan

Click here to view Michael’s video on preventive services covered under the Affordable Care Act.

Sources:

US Preventive Service Task Force

Evidence-Based Clinical Prevention in the Era of the Patient Protection and Affordable Care ActThe Role of the US Preventive Services Task Force Albert L. Siu, MD, MSPH1; Kirsten Bibbins-Domingo, PhD, MD2; David Grossman, MD, MPH3 JAMA. 2015;314(19):2021-2022. doi:10.1001/jama.2015.13154.

February 21, 2016

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