Preventive Care Services

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

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
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    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:

  • Breast-feeding support, supplies, and counseling, including costs for renting or purchasing 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
  •  
    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.

    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.

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